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Blue Cross Blue Shield of Massachusetts Clinical Pharmacist, Medicare Pharmacy Operations in Hingham, Massachusetts

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The Medicare Clinical Pharmacist is responsible for the clinical oversight of the Medicare Part D formulary/Part B strategy and Part D Star Measures. The Medicare Clinical Pharmacist is responsible for ensuring compliance with CMS regulations for the formulary and delegated functions to the Pharmacy Benefit Manager (PBM).

The Medicare Clinical Pharmacist will be the point of contact for the PBM for the Medicare formulary and any related issues. The Medicare Clinical Pharmacist will work closely with Medicare Product Management, Actuarial, Medicare Case Management and Sales teams. The Medicare Clinical Pharmacist role is to promote and retain both Medicare direct-pay members and Medicare employer-groups.

SUMMARY OF RESPONSIBILITIES AND KEY RESULTS:

  • Oversee the formularies and clinical programs for Medicare Part D plans to ensure compliance with all CMS requirements for administration and reporting.

  • Work collaboratively with the Medicare Pharmacy Operations Manager to develop the Medicare Part D formulary and Part B utilization management strategies.

  • Responsible for the execution and ongoing maintenance of the Medicare Part D formulary and Part B utilization management strategies with the internal business areas.

  • Provide clinical support and oversight of CMS required clinical programs to remain compliant and operationally effective. Including:

  • Review patient safety, appropriate utilization, and access to care reporting.

  • Review ongoing coding maintenance and claims oversight to ensure accuracy.

  • Perform clinical intervention and data analysis to identify the cause, resolve the issue and avoid further member impact.

  • Perform continuous oversight, QA testing, and close monitoring of rejected pharmacy claims to ensure formulary coding accuracy and access to care in a timely manner.

  • Lead the oversight of Part D Star measures and clinical programs to meet CMS requirements. Including:

  • Reporting results to internal/external audiences.

  • Identifying trends.

  • Creating future strategies and process improvements.

  • Represent Medicare Pharmacy Operations in various workgroups to provide clinical support and subject matter expertise on the Medicare Part D formulary/Part B utilization management strategies.

  • Collaborate with PBM and other internal/external partners to evaluate programs after implementation to ensure objectives are met.

  • Partner with Pharmacy Operations Contact Center Medicare team to ensure clinically appropriate utilization, promotion of the most cost-effective therapies, and support on operationalizing the programs.

  • Partner with Pharmacy Operations Contact Center Medicare team to configure utilization management criteria in the MHK tool.

  • This includes oversight of configuration process with Medicare Pharmacy Operations analyst.

  • Participation in monthly MHK configuration push as needed.

  • Participation in bi-monthly Pharmacy & Therapeutic committee meetings.

  • Presentation of drug monographs to committee members.

  • Presentation of Part D formulary/Part B utilization management updates.

  • Conduct MTM reviews with Medicare Members as needed.

  • Special projects as assigned.

EDUCATION AND EXPERIENCE REQUIREMENTS:

  • Minimum of professional Registered Pharmacist degree required, PharmD preferred. Graduate study in a business, public health, or health policy field will be favorably considered.

  • Unrestricted current and valid license to practice pharmacy in the state of Massachusetts.

  • 2 plus years experience in a managed care setting, either from the provider, the payer, or the PBM side of the industry, is required.

  • Proficiency in standard computational office-suite applications, including word-processing and relational database manipulation (i.e., Microsoft Excel, Access) required.

  • MTM Certification, encouraged, but not required.

SKILL AND BEHAVIORAL COMPETENCIES REQUIRED:

  • Excellent written and oral communication skills

  • Excellent interpersonal skills

  • Strong organizational and time management skills, including ability to work independently and prioritize multiple projects and assignments

  • Demonstrated strength in analysis, identification of problems and issue resolution

  • Excellent skills in teamwork and team approaches to goal setting and attainment

  • Demonstrated ability to establish and maintain positive, effective working relationships with staff, internal and external customers

  • Must be results oriented.

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

LocationHinghamTime TypeFull time

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. We provide a flexible hybrid work model in which roles are designated as resident (on site 4-5 days/week), mobile (on site 1-3 days/week), or eworker (on site 0-3 days/month).

Blue Cross Blue Shield of Massachusetts, has a COVID-19 vaccination requirement for building entry. Your offer of employment is dependent upon either being fully vaccinated for COVID-19 or an accommodation based on a disability or sincerely held religious belief, practice, or observance by submitting a request to Human Resources.

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power , Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.

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