Fallon Health

  • Senior Director, Clinical Pharmacy Management - Growing Health Plan!

    Location US-MA-Worcester
    Posted Date 3 weeks ago(7/30/2018 4:30 PM)
    Job ID
    5324
    # Positions
    1
    Category
    Senior Leadership
  • 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.

    Leads the development, implementation and maintenance of the health plan’s prescription medication benefit including, but not limited to, vendor procurement and management, outpatient formulary design, management of injectable specialty medications and oversight of all regulatory, contractual and accreditation requirements. Directs Pharmacy Operations and Medication Therapy Management program and staff to improve the quality and cost-effectiveness of pharmaceutical care of Fallon members.

    Responsibilities

    • Support pharmacy related medical management operations to achieve corporate financial Cost of Care goals for pharmacy cost and utilization.
    • Manage pharmaceutical costs and trends through analysis of industry, clinical and compliance laws and trends and advise on cost of care opportunities.
    • Recruit, retain, develop, and motivate staff in Pharmacy Operations and MTM.
    • Clearly define and communicate team performance goals for each area of responsibility and assure delivery of those goals.
    • Responsible for the budgeting/forecasting process, expense control, capital planning, operation budget of Pharmacy Department.
    • Manage PBM relationship in partnership with NDM/Contracting.
    • Working with Medical Economics, develop reports to meet project and account management needs.
    • Analyze data to identify opportunities to influence individual prescriber practices.
    • Develop and implement managed care strategies to integrate the retail pharmacy program into care management and UM programs, to include utilization, risk and case management, grievance and appeals activities.
    • Work directly, either individually or in large group settings, with prescribers to identify and address prescription utilization trends and issues of clinical performance and effect change in prescribing patterns.
    • Oversee Medication Therapy Management Program.
    • Formulate and implement delivery methodologies for the MTM program that ensure the financial performance of the program.
    • Manage the development and the on-going review of the formularies for multiple product lines.
    • Oversee Pharmacy Utilization Management processes, compliance, and staffing.
    • Support corporate effort to maintain accreditation by agencies including but not limited to CMS, MassHealth, and NCQA.
    • Meet with customers, employer groups, benefit representatives, brokers and internal account management staff to explain pharmacy utilization, pharmacy strategy, and programs for improving member satisfaction, quality, and cost management.
    • Design and interpret potential impact of benefit design changes for customers.
    • Assist in developing responses to Requests for Proposals from potential customers.
    • Support Pharmacy-related Fraud Waste, and Abuse efforts.
    • Coordinate with NDM/Provider Relations to facilitate and resolve provider pharmacy related issues and concerns.
    • Coordinate with Member Services to facilitate and resolve member pharmacy related issues and concerns.

    Qualifications

    • Doctor of Pharmacy (PharmD)
    • Or, BS Pharmacy degree with optional postgraduate training or residency, or with three to five years of experience in managed care delivery, or other clinical or management role with frequent interaction with physicians and other healthcare providers.
    • Minimum of four years clinical experience (broad scope preferred).
    • A minimum of five years of managed care pharmacy experience, including responsibility for formulary management, prior authorization and other clinical initiatives in a health plan setting required.
    • Experience with tenets of quality improvement.
    • Excellent presentation and interpersonal skills with effective oral and written communication.

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