Director of Utilization Review at Bradford Health Services optimizing resource use and ensuring compliance in healthcare delivery. Leading multidisciplinary teams and driving improvement initiatives in utilization management.
About the role
- Director of Pharmacy leading the strategic direction of the Culinary Health Fund’s pharmacy programs. Managing clinical pharmacy operations while ensuring compliance and financial objectives are met.
Responsibilities
- Manage Prescription Drug Programs: Oversee the development, negotiation, and implementation of pharmacy benefit management programs for health plans and employers.
- Provides leadership and has accountability for the performance and results of The Culinary Health Fund’s PBM and retail pharmacies
- Develops and monitors the pharmacy clinical policies and programs, where appropriate
- Leads the development of innovative clinical solutions to help manage the cost of the Fund’s pharmacy benefits, including but not limited to medication therapy management services for high-risk and general populations
- Leads the creation, maintenance, and enhancement of formularies for a variety of patient populations while working with lead clinicians and designated committees
- Ensures the success of Pharmacy Utilization Management, Prior Authorization, and other controls for all managed populations
- Negotiate Contracts: Work with pharmacies and pharmaceutical manufacturers to secure cost-effective medication options and manage rebate contracts.
- Data Analysis: Analyze drug utilization data to inform formulary strategies and ensure appropriate medication use.
- Analyzing pharmacy claims data to monitor drug spend and forecast trends
- Develops, implements, and ensures continuous quality and process improvement to deliver effective and efficient programs and services
- Regulatory Compliance: Ensure adherence to state and federal regulations regarding pharmacy benefits and prescription drug programs.
- Develops, maintains, and oversees local, state, and national regulatory compliance for all PBM services
- Provides oversight to ensure successful outcome of compliance audits/reviews (e.g., URAC)
- Relationship Management: Maintain relationships with pharmacies, healthcare providers, and other stakeholders to facilitate effective communication and service delivery.
- Collaborates with the Fund’s departments, Regional Directors and external stakeholders on service delivery including development and implementation of a network of community pharmacies to support broader healthcare delivery programs and to resolve claim issues
- Accountable for the performance of the various vendors engaged by the PBM for Pharmacy programs, analytical services and resolves issues affecting the service or financial objectives of the PBM
- Facilitates communication with network pharmacies
- Cost Management: Identifying cost-saving opportunities and developing strategies to reduce expenses.
- Provides leadership oversight for the assessment of value-based pharmacy programs to continually enhance the pharmacy programs
Requirements
- 5 ~ 7+ years of direct experience
- Working knowledge and experience in PBM contracts, benefit programs, funding arrangements, administrative arrangements, insurance products, compliance, etc.
- Strong pharmaceutical knowledge including clinical aspects and formulary development
- Knowledge of a wide-range of patient-centered and pharmacy management programs
- Bachelor's degree in pharmacy or related field or equivalent work experience required
- Doctor of Pharmacy (PharmD), preferred
- Completion of PBM (Pharmacy Benefit Manager) residency (minimum 1 year)
- Required: License in Pharmacy in good standing in the state of Nevada
- The ability to travel 15% ~ 25% as needed by the business
Benefits
- Medical
- Dental
- Vision
- Paid Time-Off (PTO)
- Paid Holidays
- 401(k)
- Short- & Long-term Disability
- Life
- AD&D
- Flexible Spending Accounts (healthcare & dependent care)
- Tuition Assistance
- Employee Assistance Program (EAP)
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