Fallon Health

  • Government Programs and Quality Clinical Pharmacist

    Location US-MA-Worcester
    Posted Date 2 months ago(4/11/2018 2:32 PM)
    Job ID
    # Positions
  • Overview

    About Fallon Health

    Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.


    The Government Programs Pharmacist will

    • Ensure compliance to all CMS, EOHHS regulations, and state mandates related to pharmacy.
    • Develop and support implementation of product specific clinical and government programs designed to improve HEDIS and STAR measures
    • Coordinate vendor activities related to implementation of quality programs for Fallon Health
    • Coordinate utilization management related to government programs





    • Implement pharmacy benefits and regulatory changes to ensure compliance with regulatory requirements
    • CMS CDE reporting requirements and monitoring
    • CMS/NCQA audits and Universe monitoring
    • Updates to policies and procedures
    • CMS OMS reporting
    • CMS MTM Reporting and monitoring
    • Regulatory requirements and reporting updates (with IT assistance)
    • In collaboration with the FH Quality team, develop and implement programs or activities to improve STAR and HEDIS measures
    • Collaborate with vendors to incorporate programs designed to improve quality measures
    • Medicare Quality reports and initiatives
    • Website criteria updates and Medicare pharmacy description updates
    • PBM monitoring for Utilization Management functions and regulatory requirements
    • Monitoring that Prior Authorizations and Coverage Determinations are properly evaluated
    • Criteria posting for Provider website and update of criteria tracker – with Digital Content team
    • Review of CMS call letter and tech specs for FA, CD and MTM and P&P updates
    • CMS Data Validation (CDE, MTM)
    • Oversight of decisions made on review of medication PA/exception requests, as well as completing data analysis and various clinical projects.
    • Collaborate with the business to develop process changes to ensure compliance with regulatory changes related to Medicare Part D and EOHHS and state mandates
    • Read, interpret, summarize, and assess the impact on business operations of Medicare and or accrediting body regulations, guidance, and communications
    • Develop corrective action plan responses when required
    • Support the administration of internal and external audits, CMS Complaint Tracking Module issues, the annual Part D application process, reporting requirements, and data validation audits
    • Support the testing and validation of the Medicare Prescription Drug Plan Finder, formulary, marketing materials, and the member portal
    • Provide training and presentations to internal departments on an as needed basis
    • Document and maintain project plans and status reports as related to the annual Part D implementation process, audits, and other ad hoc initiatives as needed
    • Participate in the oversight of subcontracted vendors to ensure compliance with Medicare and accrediting body requirements
    • Participate in review of medications for formulary placement and development of prior authorization criteria
    • Review prior authorizations for medical drug 



    RPH or PharmD



    Current License to practice as pharmacist in Massachusetts without restriction



    5 years with at least three years in a managed care environment with Medicare and Medicaid; 1-2 years Professional experience practicing as a clinical pharmacist




    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed