The Pharmacy Benefit Services Strategy Specialist will be responsible for supporting pharmacy benefit management initiatives and strategies to include working as part of the pharmacy team to implement and maintain pharmacy benefits, maintaining the integrity of clinical programs, and identifying and resolving technical, operational, and vendor problems. The Pharmacy Benefit Services Strategy Specialist also provides oversight of regulatory filings and website content.
Responsible for delegation oversight of multiple PBM vendors for all lines of business (Medicare, Commercial, USFHP).
Demonstrates strong understanding of Center for Medicare and Medicaid Services (CMS) requirements and regulations related to Medicare Advantage and Medicare Part D operations and compliance.
Manages pharmacy regulatory submissions to CMS, TDI, OSI, LDI & DoD
Consult with compliance divisions to provide strategic enterprise support.
Provides subject matter expertise on Medicare, Health Insurance Exchange, and DoD regulations and guidelines applicable to pharmacy processes.
Interprets policies and procedures and establishes guidelines to support pharmacy programs and ensure regulatory compliance. Update departmental policies as needed.
Informs and educates internal and external stakeholders on the features and services of the pharmacy programs.
Supports achievement of the pharmacy program financial and clinical outcome goals.
Supports internal and external audits.
Makes strategic recommendations including benefit design and formulary analysis, provision of clinical drug information, oversight of delegated P&T functions, rational drug formulary positioning, online system edits and restrictions, on-going clinical product evaluations, and client pharmacy benefit utilization and performance trends.
Participates on multidisciplinary quality and operational improvement teams as appropriate.
Participates in meetings, serves on committees and represents the pharmacy department.
Reviews key Part D key functions for evidence to document whether it meets compliance requirements for accuracy, includes, but not limited to: Claims, Coverage Determinations, Formulary Administration, PDE, and Reporting.
Uses clinical expertise to lead development of program success measures and performs periodic assessments of programs for Part D / PBM/ Coverage Determinations.
Communicate pharmacy-related written, digital, and telephone inquiries with the pertinent department that sent the original inquiry, i.e. Complaints, Appeals, and Grievances (CAG), Member Services, or Case Management.
Performs oversight of Comprehensive Medication Reviews (CMR) for Medicare members as part of the vendors Medication Therapy Management (MTM) Program as scheduled
Monitors STARs Measures.
Ensures timely clinical recommendations of appeals to the Chief Medical Officer to meet regulatory timelines.
Maintain complete confidentiality of company related business.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.