Summary of Position
- Direct and provide clinical and operational support for sales, account management, actuary, procurement and underwriting in
key pharmacy leadership role.
- Responsible for educating the sales and account management departments about pharmacy benefits, supporting new
Account RFP, leading new benefit set-up for Pharmacy benefits with the PBM, and addressing any/all account management
- Responsible for accountability for Pharmacy delegate performance and day to day executive contact with delegate.
Sales And Account Support
- Provide enterprise support for sales and underwriting with RFP’s for new business and provide ongoing support to
- Partner with brokers to answer questions and provide education regarding benefit offerings at ConnectiCare and/or
- Develop and maintain a suite of pharmacy utilization reporting packages, supporting account business reviews.
- Provide pharmacy benefit consulting support, identifying trends and high cost claimants when needed.
- Review drug pipeline with new or existing accounts, actuary, and underwriting on demand to identify and plan for
future drug spend.
Pharmacy Systems And Operations
- Implement and monitor pharmacy benefit installation and testing across the enterprise under the direction of the VP,
Enterprise Pharmacy Solutions to meet clinical objectives, control costs, monitor pharmacy vendor performance,
contractual compliance and review pharmacy network as desirable.
- Act as primary contact for pharmacy or Pharmacy Benefit Manager (PBM) questions to including benefits, point of
sale rejects, utilization management, or address and resolve enrollment and benefit design discrepancies.
- Lead pharmacy operations for all LOBs. Strategize with Formulary/UM and Quality directors to ensure flawless
operations for each LOB.
- Subject Matter Expert (SME) for pharmacy benefits for sales, account management, underwriting, and actuary and
responsible for the oversight of new benefit configuration and benefit setup.
- Make decisions within the limits of the plan policies and procedures relative to the health care benefit.
- Develop member communications in collaboration with the PBM Communication team related to benefits or
- Demonstrate proficiency with the principles and methodologies of process improvement, maintaining operational and
- Negotiate contract provisions, SLAs and delegated services with the delegates, including any performance penalties.
Continuously assess contract for opportunities to amend provisions to address changes in delegate or Enterprise
- Address escalation requests from the Relationship Manager (RM), and in some instances, DVOC or SMEs and works
with delegate senior management counterpart to resolve each request.
- Review and assess monitoring results, accepting or questioning the data and results supplied by the delegate.
- Develop the measures of remediation success for CAPs or other performance improvement actions.
- Work with the RM and SMEs to assess and report poor performance, CAP updates or any concerns to the DVOC.
- Review and approve CAPs. Apprise of CAP status, implementation completion and post-implementation monitoring.
- Assess financial value proposition of the delegate relationship to the organization and report quarterly to the DVOC.
- Assess any qualitative impact of the delegate’s performance on member experience and integrate into performance
assessment measures, escalating any issues to the DVOC.
- Perform all reports to the DVOC about the delegate, including CAPs, audit results, CAP updates, CAP closure requests,
as well as any ad hoc performance reports.
- Advise DVOC of changes in delegate status (i.e. delegates services, lines of business), delegate terminations and new
delegates and provides periodic updates until changes are executed.
- Hire, develop, manage and motivate a performance-based pharmacy operational team providing ongoing direction
- Create business plans, ensure appropriate staffing, productivity and compensation levels.
- Develop policies and procedures for function and team.
- Assure staff accountability through routine observation, reporting, coaching, counseling, and through timely
preparation of staff performance appraisals. Take appropriate action on employee issues related to job performance
and professional conduct.
- Use, protect, and disclose EmblemHealth patients’ protected health information (PHI) only in accordance with Health
Insurance Portability and Accountability Act (HIPAA) standards.
- Ensure effective, on-going staff training and development activities to support staff orientation, knowledge and skill
enhancement, proficiency/productivity and professional growth for Pharmacy Operations staff.
- Responsible for budget development, forecast and management in conjunction with VP, Enterprise Pharmacy
- Partner with Risk Management to protect against department related risks, and guarantee that the department
complies with all applicable laws.
- Perform other duties as assigned.
Education, Training, Licenses, Certifications
- Bachelor of Pharmacy Degree required; PharmD Preferred.
- Unrestricted license to practice pharmacy.
Relevant Work Experience, Knowledge, Skills, And Abilities
- 8 - 10 years management experience.
- Minimum of 10 years managed care or related experience.
- Minimum of 5 years of pharmacy operations experience, including benefit installations.
- Minimum of 5 years’ experience in Pharmacy Benefits Management vendor oversight; Comprehensive understanding of third-
party pharmacy benefits plan parameters.
- Strong leadership capabilities.
- Previous sales experience.
- Excellent presentation skills and ability to communicate clearly, both verbally and in writing; Ability to articulate clinical
information to non-health care audience.
- Skilled in project management with ability to motivate internal and external collaborations to see projects through to
- Demonstrated proficiency with reporting of data and the ability to analyze, draw conclusions, and make recommendations
from qualitative and quantitative information and data.
- Self-motivated, with demonstrated ability to work independently with minimal supervision.
- Knowledge of Utilization Management, appeal, and grievance guidelines.
- Understanding of pharmacy-related analytics.
- Experience leading high performing teams.
- Ability to influence without direct control.
- Incumbent must have a demonstrable work history involving complex and innovative problem-solving for which there may
not be clearly established guidelines and proven solutions.
- Proven track record of satisfying many stakeholders with competing interests.
- Requisition ID: 1000000416