Fallon Health Vice President, Clinical Pharmacy Strategy - Growing Health Plan! in Worcester, Massachusetts
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.
Lead and implement strategies to achieve corporate financial Cost of Care goals for pharmacy cost and utilization through analysis of industry trends, clinical issues, regulatory and compliance requirements, and advise on cost of care opportunities.
Develop and implement managed care strategies to integrate the pharmacy program into care management and UM programs, to include utilization, risk and case management, grievance and appeals activities.
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.
Oversees relationships with the pharmaceutical industry
Chair of the Pharmacy and Therapeutics CommitteeWorking with Medical Economics, develop reports to meet project and account management needs.
Analyze data to identify opportunities to influence individual prescriber practices.
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.
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.
Active Massachusetts license or ability to obtain MA license
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. Board experience in managed care with particular emphasis in managed Medicaid and Medicare Part D.
Experience in managing pharmacy trend through vendor management, formulary management and collaborative relations with providers, either working on the payer side or working with providers in an integrated delivery system/ACO.
Experience managing both professional staff (other pharmacists) and support staff.
A comprehensive knowledge of Pharma, PBMs, rebates, and 340B pricing.
Minimum of ten years clinical experience and at least five in managed care or ambulatory clinical operations leadership.
Job ID 5371
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