Mgr Clinical Pharmacy Prgm S+P

About Us

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

Job Profile

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Job Profile

JOB SUMMARY

The Clinical Pharmacy Program Manager provides highly specialized integrated clinical pharmacy services to the health plan. This position is responsible for managing both clinical and operational functions for pharmacy benefit administration for assigned line of business.

JOB SPECIFICATIONS AND CORE COMPETENCIES

• Serve as clinical resource supporting Care Management, Service Coordination, and Utilization Management functions on medication-related projects and inquiries.
• Responsible for performing review of medication appeal requests, and prior authorization requests for medical benefit drugs.
• Conduct oversight over prior authorization criteria and delegated utilization management functions performed by PBM.
• Analyze utilization and prior authorization data to identify drug utilization trends and cost-savings opportunities.
• Develop and implement quality and cost-saving initiatives to reduce drug costs and improve outcomes.
• Oversees PBM performance of delegated functions for assigned line of business.
• Perform retrospective drug utilization review and clinical consultation with members and providers.
• Create and refine policies and standard operating procedures for pharmacy operation processes.
• Monitors and implement regulatory changes from CMS, HHSC, and TDI impacting administration of pharmacy benefits for assigned line of business.
• Collaborate with cross-functional teams to implement strategies to achieve Companys annual strategic goals as assigned.
• Supervise clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned.
• Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plans, and other duties as assigned.

QUALIFICATIONS:

• Education/Specialized Training/Licensure: Bachelors degree in pharmacy if candidate does not have a Doctor of Pharmacy degree required. (Bachelors degree is not required if candidate has Doctor of Pharmacy degree.)
• Active license as a pharmacist in Texas required; or will have Texas pharmacist license prior to start date required.
• Doctor of Pharmacy degree preferred
• Work Experience (Years and Area): Minimum 5 years of applicable managed care pharmacy experience as a registered pharmacist.
• or at least 4 years of relevant pharmacy experience AND completion of advanced training (i.e., completion of PGY1 managed care pharmacy residency, master, or doctorate degree in a quantitative discipline such as finance, accounting, business administration, or informatics)
• Strong experience with drug utilization management required
• Minimum 4 years experience in Medicare, Medicaid, and/or Marketplace with a Health Plan or PBM required.
• Experience with advanced Excel required
• Experience with SQL preferred
• Strong experience with Medication Therapy Management preferred
• Software Proficiencies: Microsoft Office (Word, Excel, Outlook, Power Point) Visio preferred.

Job Family/Job Title Competencies

• Problem Analysis
• Results Oriented
• Attention to Detail
• Leadership
• List any additional competencies
• Exceptional Verbal and Written Communication
• Managing Conflicts
• Customer Oriented
• Ability to work independently with minimal supervision
• Taking initiative

INTERPERSONAL SKILLS

• Ability to explain and communicate complex ideas with a diverse population
• Work Environment:
• Office setting with low partitions and open floor plan
• Work in a high-rise building
• Close Paper/Computer work
• Option for remote work

Benefits and EEOC

Harris Health System's benefits program is designed to provide you with more flexibility and choices in meeting your specific needs. Harris Health System's benefits program allows you to protect your income in case of illness, death and disability, and to help you save for retirement.

It is the policy of Harris Health System to provide equal opportunity for all applicants for employment regardless of political affiliation, race, color, national origin, age, sex, religious creed or disability. Applicants may request any reasonable accommodation(s) to participate in the application process.