Manager of Pharmacy Services, Medicare

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary

Reporting to the Director of Clinical Pharmacy, the Manager of Pharmacy Services, Medicare, is primarily responsible for oversight and management of the Medicare Part D clinical programs and daily operations, including initiatives that impact star ratings and ensuring compliance with regulatory requirements. Additionally, responsibilities include assisting with pharmacy vendor and contract management, resolution of member/provider inquiries, drug utilization management, and quality improvement activities pertaining to Medicare. The Medicare Manager of Pharmacy Services will interface with physicians, nurses, internal employees, PBM representatives and supervise Medicare pharmacy support staff as needed.

Our Investment In You

• Full-time remote work
• Competitive salaries
• Excellent benefits
  
  

Key Functions/Responsibilities

• Oversight and management of Medicare Part D daily operations including coverage determination activities, formulary development, program implementation and responding to member and provider inquiries.
• Assist with oversight of the terms and conditions of each of the Plan’s pharmacy vendor contracts, including the PBM and specialty pharmacies and ensuring policies and procedures are compliant with Medicare and Medicaid requirements as applicable.
• Implement pharmacy benefits and regulatory changes to ensure compliance with programmatic and regulatory requirements of CMS, state Medicaid agencies, and NCQA as applicable.
• Responsible for compliance with regulatory reporting for the SCO and Medicare Advantage WellSense products.
• Develop, implement, and/or maintain internal policies and procedures to meet regulatory mandates and requirements.
• Provide care management support including performing medication assessments, ensuring timely and quality consultations to care management, as well as direct member outreach for medication reconciliation needs.
• Develop and implement clinical and strategic initiatives to achieve cost, quality and utilization objectives as well as to improve/optimize Plan’s star rating for Part D elements
• Monitor market trends to proactively position the Plan competitively in market place.
• Analysis of pharmacy claim data and reports to identify key drivers of cost / utilization changes and opportunities for improvement; communicate findings within the department and the health plan.
• Facilitate internal and regulatory pharmacy audit activities.
• Participate in interdisciplinary committees and CMS-sponsored calls as necessary.
• Maintain up to date knowledge on Medicare and Medicaid guidance as it pertains to the administration of the pharmacy benefit.
• Communicate effectively with key external constituents as needed (clinics, physician group, hospital) regarding pharmacy program, formulary and pharmacy processes.
• Hire, orient and provide supervision, performance evaluation and professional development to all clinical and operational staff for Medicare.
• Regular and reliable attendance is an essential function of the position.
  
  

Qualifications

Education Required:

• Bachelor of Science in Pharmacy and appropriate state licensure.
• Doctor of Pharmacy preferred.
• Residency training and Board of Pharmaceutical Specialties (BPS) certification in Pharmacotherapy or Geriatrics preferred.
  
  

Experience Required

• 5+ years of clinical experience.
• 3+ years management/supervisory experience.
• 2+ years of prior managed care experience with Medicare Managed Care/Part D preferred.
  
  

Certification Or Conditions Of Employment

• Current unrestricted licensure as a pharmacist in the Commonwealth of Massachusetts.
  
  

Competencies, Skills, And Attributes

• Extensive knowledge of drug products, medical therapeutics, pharmacokinetics, and disease states.
• Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
• Demonstrated strong organization and time management skills.
• Able to work in a fast paced environment; ability to multi-task.
• Experience with standard Microsoft Office applications, particularly MS Outlook and MS Word, and other data entry processing applications.
• Strong analytical and clinical problem solving skills.
• Detail-oriented and ability to manage multiple priorities effectively.
  
  

Working Conditions And Physical Effort

Occasional travel (<5%) may be required.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Required Skills

Required Experience