Medicare Pharmacist / Job Req 939818321

Hybrid: Applicants must be a California resident as of their first day of employment.

PRINCIPLE RESPONSIBILITIES:

Under the general direction of the Senior Director, Pharmacy Services, the Medicare Pharmacist is responsible for the planning, implementation, strategic oversight, and overall operations of Alameda Alliance for Health's Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) product. Working either as individual contributor or directing Pharmacy Technician(s) or Clinical Pharmacist(s) (as assigned), the Medicare Pharmacist will work cross-functionally to design, implement, and monitor various interventions that drive quality performance, improve provider and member engagement, and comply with CMS regulatory requirements.

Equal responsibility will be given to developing and executing clinical pharmacy improvement programs to achieve 4 or above Medicare Part D Star Ratings. This individual will have a deep understanding of Medicare Star Ratings pharmacy-related measures, scoring methodology, and quality improvement strategies to optimize medication adherence, patient outcomes, and overall plan performance. The Medicare Pharmacist position is expected to remain current with market/industry trends and best practices to ensure the Medicare D-SNP pharmacy program and Star strategies are implemented in a budget conscious, high quality, and timely manner.

Principal responsibilities include:

* Work with leadership to design and implement Star strategies for Alameda Alliance for Health's Medicare Advantage D-SNP product, ensuring alignment with organizational goals and regulatory requirements.

* Prioritize key pharmacy-related Star measures (e.g., medication adherence for diabetes, hypertension, cholesterol management, CMR completion rates) and develop targeted strategies to improve performance and close gaps in care.

* Monitor and oversee the execution of pharmacy-driven intervention programs aimed at improving medication adherence, optimizing medication therapy management (MTM), and reducing inappropriate medication use.

* Act as a liaison and subject matter expert (SME) for pharmacy quality performance between key stakeholders, including pharmacy benefit managers (PBMs), internal departments, prescribers, pharmacies, and community partners, to drive intervention program adoption and commitment.

* Utilize data analytics and reporting tools to identify insights, track progress, and inform decision-making for pharmacy Star initiatives.

* Oversee pharmacy performance reporting, data analysis, and risk identification to proactively address trends, barriers, and improvement opportunities in pharmacy-related Star measures.

* Develop and facilitate provider and internal training sessions to improve understanding and execution of pharmacy-related Star measures and quality initiatives.

* Create productivity standards, roadmaps, reporting structures, and Key Performance Indicators (KPIs) for pharmacy quality initiatives.

* Support and collaborate with Policy & Procedure owners to draft, revise, develop and maintain necessary policies and desktop Standard Operating Procedures related to D-SNP operations.

* Oversee and manage PBM and MTM vendors. Track and monitor deliverables. When necessary, develop and implement corrective action plans (CAP).

* Coordinate with other Pharmacy staff to develop clinical review criteria and support Pharmacy & Therapeutics Committee presentations as assigned.

* Manage the CMS Complaint Tracking Module (CTM), reviewing complaints and escalating through the Alliance and advising the Compliance Committee as necessary.

* Review daily rejected claims reports utilizing CMS Transition Monitoring Program Analysis (TMPA) and Formulary Administration Analysis (FAA). Focus on rejections that can be validated using the formulary including: Product Not Covered, Prior Authorization, Quantity Limit and Step Therapy, and determine whether rejection resulted in a subsequent paid claim (and timing of paid claim). Document and remediate questionable rejections to comply with CMS rules.

* Review on a monthly basis all Coverage Redeterminations (appeals) and assess for clinical appropriateness, timeliness, correct Medicare Part B versus Medicare Part D determination and proper decision-making procedures. Review member letters for correctness.

* Review on a monthly basis EOB sample to ensure claims and costs are reported accurately in a CMS approved format.

* Review Part D Patient Safety Reports and other clinical programs to improve Part D quality measures and raise Medicare Star ratings.

* Download and review PDE outlier tickets released by Acumen. Coordinate with the PBM to review the outlier PDE and create an appropriate response, then upload the responses to Acumen by the deadline. Monitor post-submission activity to ensure the PDE action communicated to CMS in the Acumen responses is completed as indicated.

• Review and decision Coverage Determinations and Redeterminations, Exception Requests, and Member Complaints using NCD, LCD, or other clinical criteria

* Prepare and submit Part D materials and reports to CMS.

* Respond to CMS ad-hoc requests.

ESSENTIAL FUNCTIONS OF THE JOB:

• Assumes responsibility and exercises good judgment in making decisions within the scope of authority of the position.
• Demonstrate expertise in CMS Medicare pharmacy benefit delivery (Part B and Part D) and oversight.
• Demonstrate expertise in CMS Medicare Star technical specifications and NCQA pharmacy-related quality measures.
• Develop and implement successful pharmacy quality improvement interventions, with a focus on improving Star ratings and optimizing medication-related health outcomes.
• Organize and facilitate pharmacy Star-related meetings and project updates.
• Demonstrates strong organizational, time management, and project management skills and multi-tasking abilities.
• Provides support to the Project Management Office (PMO) and various enterprise-wide activities based on availability.
• Provides support to the Alliance Compliance Committee as necessary.
• Works effectively when independent as well as collaboratively and supports team decisions.
• Adapts to changes in requirements/priorities for daily and specialized tasks.
• Produces accurate and precise work, detects discrepancies, and resolves discrepancies all while meeting deadlines.
• Demonstrates analytical skills and problem-solving skills as well as formulates and communicates recommendations for improvements as needed.

PHYSICAL REQUIREMENTS:

• This position may require occasional on-call weekend and holiday work.
• Constant and close visual work at a desk or a computer.
• Constant sitting and working at a desk.
• Constant data entry using a keyboard and/or mouse.
• Frequent use of a telephone headset.
• Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.

Number of Employees Directly Supervised: 0

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

* A graduate of an accredited School of Pharmacy with either BS Pharmacy or Doctor of Pharmacy degree.

* Licensed and in good standing with the CA State Board of Pharmacy.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum of three (3) years of experience in the managed care industry (Medicare Advantage-related experience preferred).
• Minimum of two (2) years of experience in quality improvement (Medicare Star Ratings and HEDIS experience preferred).
• Experience in managed-care pharmacy preferred.
• Experience in project management, program management, or product development preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Audit experience preferred.
• Strong understanding of Pharmacy Star measures, CMS Star Rating methodology, and regulatory requirements.
• Excellent written, verbal, and interpersonal communication skills, and ability to successfully interact with people at all levels.
• Ability to facilitate meetings, manage complex initiatives, and make presentations before groups consisting of management and staff.
• Exhibits good planning and implementation skills to ensure work is completed on time and to expected quality levels.
• Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, while maintaining effective, high-performance teams.
• Strong organizational skills with the ability to effectively prioritize multiple tasks and meet deadlines.
• Ability to communicate effectively orally and in writing.
• Basic knowledge of the business, economic, demographic, and political trends and developments affecting healthcare in general.
• Intermediate skills in Microsoft Office Suite including Outlook, Word, Excel, Visio, and PowerPoint.
• Ability to manage confidential information with appropriate discretion.
• 5% to 10% occasional business travel required.

SALARY RANGE: $142,043.20 - $213,075.20 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.