Staff VP Pharmacy Operations
Company Name:
UniCare Life & Health Insurance Company
Job Description
Responsible for leading and directing the pharmacy benefit management operations, including claims, eligibility, formulary, implementations and HCMS call center through a staff of Pharmacists and non-Pharmacists. Ensure the operational areas meet state and CMS requirements in an efficient manner through process improvement, improved productivity, improved turnaround time, reduced costs and increased quality results. Functional responsibility includes prior authorization operations, eligibility, HCMS call center and claims.
PRIMARY
Responsibilities:
Develops, implements, and manages a strategic plan for pharmacy operations; resolves problems and provides guidance to team.
Management of functional SG&A; budget and effective management of capital and human resources.
Identifies and communicates quality and process improvement opportunities and leads process improvement changes; develops and execute appropriate department work flows
Develops, implements and monitors processes, policies and procedures to optimize work processes, maximize efficiencies and ensure compliance with corporate, state, regulatory, NCQA and URAC requirements.
Ensure benefit configurations meet state and CMS requirements; responsible for ensuring policies and procedures are updated based on CMS and other applicable regulations.
Oversees daily management of PBM operational items.
Establishes quality and productivity standards for operations positions and programs.
Responsible for the prior authorization system administration and maintenance of clinical protocols.
Responsible for disaster planning and business continuity recovery plan.
Co-chairs Pharmacy Advisory Committee and participates on other committees such as Vendor Oversight, Quality Improvement Committee and other committees as required.
Leads the rebate dispute resolution process and other claim related process needs.
Develops and implements formal audit procedures for Pharmacy Operations, including claims adjudication system and HCMS Call Center.
Develops and mentors staff to create depth of resources in alignment with departmental needs.
Other Duties as Assigned.
Job Qualifications
Education: Bachelor's Degree in business related field, BS Pharm/Pharm D, Advanced business degree - MS or MBA Preferred
Minimum of 12 years' experience in pharmacy department management within managed care or Pharmacy Benefit Management Operations or equivalent. Medicaid and Medicare Part D experience. At least 7 years of leadership/management experience of clinical and non-clinical staff. Strong working knowledge of pharmacy benefit management and managed care. Total Quality Management, Six Sigma or similar process improvement experience.
Preferred: Minimum of 1 year managed care experience and knowledge of Managed Pharmacy Environment, Retail pharmacy, HMO or PBM experience. Certifications or Licensures in Process Improvement, Total Quality Management, Six Sigma or equivalent. Working knowledge of pharmacy claims processing, experience with web based prior authorization applications. Pharmacist with PBM experience preferred.
This individual should be able to perform basic data queries and analysis with applications such as Microsoft Access or Excel. Strategic skills, develops responses to key competitor actions and threats, and identifies and integrates organizational strategies to achieve and sustain competitive advantage. Develops strategies that position the business to shape and capitalize on emerging customer and market needs. Develops strategies that leverage the core capabilities and competencies of the company.
EOE.M/F/Disability/Veteran
Once an offer is accepted, all external applicants are subject to a background investigation and if appropriate, drug testing. Offers of employment shall be contingent upon passing both the background investigation and drug testing (if required).
Current WellPoint associates: All referrals must be submitted through the formal associate referral process on WorkNet. Official guidelines for the associate referral program can be found in My HR.Estimated Salary: $20 to $28 per hour based on qualifications.
UniCare Life & Health Insurance Company
Job Description
Responsible for leading and directing the pharmacy benefit management operations, including claims, eligibility, formulary, implementations and HCMS call center through a staff of Pharmacists and non-Pharmacists. Ensure the operational areas meet state and CMS requirements in an efficient manner through process improvement, improved productivity, improved turnaround time, reduced costs and increased quality results. Functional responsibility includes prior authorization operations, eligibility, HCMS call center and claims.
PRIMARY
Responsibilities:
Develops, implements, and manages a strategic plan for pharmacy operations; resolves problems and provides guidance to team.
Management of functional SG&A; budget and effective management of capital and human resources.
Identifies and communicates quality and process improvement opportunities and leads process improvement changes; develops and execute appropriate department work flows
Develops, implements and monitors processes, policies and procedures to optimize work processes, maximize efficiencies and ensure compliance with corporate, state, regulatory, NCQA and URAC requirements.
Ensure benefit configurations meet state and CMS requirements; responsible for ensuring policies and procedures are updated based on CMS and other applicable regulations.
Oversees daily management of PBM operational items.
Establishes quality and productivity standards for operations positions and programs.
Responsible for the prior authorization system administration and maintenance of clinical protocols.
Responsible for disaster planning and business continuity recovery plan.
Co-chairs Pharmacy Advisory Committee and participates on other committees such as Vendor Oversight, Quality Improvement Committee and other committees as required.
Leads the rebate dispute resolution process and other claim related process needs.
Develops and implements formal audit procedures for Pharmacy Operations, including claims adjudication system and HCMS Call Center.
Develops and mentors staff to create depth of resources in alignment with departmental needs.
Other Duties as Assigned.
Job Qualifications
Education: Bachelor's Degree in business related field, BS Pharm/Pharm D, Advanced business degree - MS or MBA Preferred
Minimum of 12 years' experience in pharmacy department management within managed care or Pharmacy Benefit Management Operations or equivalent. Medicaid and Medicare Part D experience. At least 7 years of leadership/management experience of clinical and non-clinical staff. Strong working knowledge of pharmacy benefit management and managed care. Total Quality Management, Six Sigma or similar process improvement experience.
Preferred: Minimum of 1 year managed care experience and knowledge of Managed Pharmacy Environment, Retail pharmacy, HMO or PBM experience. Certifications or Licensures in Process Improvement, Total Quality Management, Six Sigma or equivalent. Working knowledge of pharmacy claims processing, experience with web based prior authorization applications. Pharmacist with PBM experience preferred.
This individual should be able to perform basic data queries and analysis with applications such as Microsoft Access or Excel. Strategic skills, develops responses to key competitor actions and threats, and identifies and integrates organizational strategies to achieve and sustain competitive advantage. Develops strategies that position the business to shape and capitalize on emerging customer and market needs. Develops strategies that leverage the core capabilities and competencies of the company.
EOE.M/F/Disability/Veteran
Once an offer is accepted, all external applicants are subject to a background investigation and if appropriate, drug testing. Offers of employment shall be contingent upon passing both the background investigation and drug testing (if required).
Current WellPoint associates: All referrals must be submitted through the formal associate referral process on WorkNet. Official guidelines for the associate referral program can be found in My HR.Estimated Salary: $20 to $28 per hour based on qualifications.
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