Sr Clinical Pharmacist, Medicare and Duals
 Mass General Brigham Health Plan | |
 United States, Massachusetts, Somerville | |
| 399 Revolution Drive (Show on map) | |
 Jan 27, 2025 | |
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Principal Duties and Responsibilities:
* Develop Medicare and Dual-eligible Custom Formularies: o Perform comprehensive analysis of pharmacy data (including but not limited to claims, competitor comparisons, trend analysis and market data) to develop formulary structure and drug coverage recommendations o Develop custom formulary recommendations supporting Medicare Star ratings and other measures set forth by applicable governing bodies o Prepare materials for presenting custom formulary coverage and changes to various committees o Responsible for building and reviewing custom formulary submission files for accuracy and compliance with all CMS requirements o Perform extensive analysis on custom formulary submission files to ensure accuracy and compliance with Centers for Medicare and Medicaid Services (CMS) requirements o Develop and review various pharmacy-related, Medicare and Dual-eligible plan required member materials and web content ensuring accuracy and schedule of posting is followed o Work collaboratively with Clinical Pharmacist and coordinate with other Medicare Pharmacy Analysts to finalize proposed custom Medicare and Dual-eligible formularies for presentations at various required committees for approval * Maintain Medicare and Dual-eligible Custom Formularies: o Manage and coordinate various aspects of Medicare and Dual custom formulary submissions, updates, reviews o Track new product approvals and launches to ensure new drug reviews and coverage decisions are made within required CMS timelines o Manage developing and updating formulary-related member documents o Responsible for reviewing, developing, and updating Medicare CMS submissions, and related content according to CMS timelines and requirements o Manage and take lead on Medicare Clinical Formulary source of truth documents while obtaining input and reviews done by the Clinical Pharmacist and other Medicare Pharmacy Analysts * Review all CMS and applicable regulatory body updated regulations, requirements, and frequent memos to ensure continued compliance o Responsible for coordinating with various stakeholders for any actions required involving pharmacy o Track all memos and Clinical Pharmacy Operations team actions for future audits * Ensure Readiness for Medicare and Dual-eligible Plan Audits o Maintain high-quality, and utilize CMS best practices in documentation related to formulary audit documents o Represent Medicare Clinical Pharmacy Operations team and MGBHP in all pharmacy-related audits as a Medicare and Dual-eligible formulary and Pharmacy subject matter expert (SME) o May include support or speaking roles o Key point person for pharmacy-related research and responses o Record and maintain records before, during and after audit * Participate in Pharmacy Trend Management: o Perform data collection and analysis to develop recommendations of strategies to maximize high-quality, cost-effective strategies o Develops and leads monitoring, tracking, and reporting related to trend and pharmacy strategies o Develop tracking grids related to drug launches, Medicare eligibility, state mandates and formulary updates o Oversee aspects of implementation of formulary and pharmacy-related strategies * Lead various aspects of pharmacy and Pharmacy Benefit Manager (PBM) oversight and monitoring of pharmacy and formulary benefit to ensure Medicare and Dual plan compliance * Lead clinical implementation, monthly maintenance, and oversight of formulary files for various broker exchanges on a monthly and yearly basis * Develop and manage oversight of pharmacy-related vendors to ensure compliance with CMS Medicare and Dual-eligible plan requirements * Develop internal and external facing educational materials, newsletters and talking points related to Medicare and Dual pharmacy content * Attend and present pharmacy material at various committees as needed including but not limited to Pharmacy and Therapeutics (P&T), Drug Coverage Committee (DCC), etc. * Manage and review various CMS Medicare and Dual plan internal reporting related to pharmacy * Work independently and in collaboration the larger Medicare Clinical Pharmacy Operations team * Address, escalate and track pharmacy related issues in coordination with the Medicare Clinical Pharmacy team and the PBM * Coordinate and play a lead role in work with other specialists and analysts on the team * As an integral member of a larger clinical team, may be asked to provide support and/or collaborate with Clinical Pharmacist(s) and larger clinical team as a whole on other lines of business. * Hold self and others accountable to meet commitments. * Ensure diversity, equity, and inclusion are integrated as a guiding principle. * Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. * Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization. * Other duties as assigned with or without accommodation. Qualifications: * PharmD and a valid unrestricted license, plus three years of Medicare and or Dual-eligible plan pharmacy related experience. * Minimum five years' experience in managed care pharmacy. * Experience with benefit and drug coding logic for adjudication and formulary management. * Experience with Medicaid and/or Dual Plans. * Experience with CMS audits. Skills/Abilities/Competencies: * Proficiency in Microsoft Word and Excel. * Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value. * Bring fresh ideas forward by listening to and working with employees and the people we serve. * Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner. * Strong, demonstrated track record of an ability to execute on time, on budget, and on scope. * Strong aptitude for technology-based solutions. * Ability to inject energy, when and where it's needed. * Current in healthcare trends. * Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be." * Ability to develop, introduce, defend, and gain support for a new ideas and approaches. * Excellent leadership skills and leadership track record. * Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. Strong verbal, active listening, and written communication skills required. * Ability to view the long-range trends and cycles of the business and industry and see the "big picture." * Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions. * Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy. * Excellent interpersonal skills, including the ability to influence others at all levels of an organization. * Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. * Unquestionable integrity. About Us: Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated. We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more. Physical Requirements
Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. | |