Lumeris · 23 hours ago
Vice President, Health Plan Pharmacy
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Responsibilities
Provides strategic direction for the department(s). Oversees, coaches, mentors, motivates, supports, and develops a large cross-functional team of seasoned people leaders. Oversees or supports goal setting/review, regular guidance and 1-1 check ins, career development/planning, upskilling, resource allocation, staffing, budget management, DE&I initiatives, and other People & Culture programs/activities as needed. Fosters accountability and collaboration to ensure team member and overall team success.
Identifies, develops, and oversees team member educational needs, with the goal of optimizing skills and knowledge of emerging approaches to quality/process improvement.
Writes, reviews, and seeks approval for policies and procedures, ensuring that both the departmental and organizational needs are met.
Develops, implements, and impacts clinical pharmacy strategies which results in high-quality, cost-effective pharmacy management and outcomes. Advises on client CMS Account Management calls as requested.
Serves as a subject matter expert for clients' Part D and Part B drug benefit designs as part of the annual CMS bid process.
Oversees daily operations for Part B drug prior authorization and Part D appeals request procedures using best practices and quality standards as defined by CMS and NCQA. Ensures compliance with all CMS and NCQA pharmacy related regulations and reporting requirements.
Develops and delivers the pharmacy program budget based on the organization's goals.
Monitors, evaluates, and presents Plan pharmacy data including reporting of trends for drug utilization, drug costs, and quality metrics (e.g., Part D Star, NCQA). Develops and recommends possible strategies to Lumeris clients to promote cost-effective therapy and quality of care for members.
Acts as content creator and Chair of both the Essence Healthcare and Lumeris Pharmacy Oversight Committees. Serves as an advisor, content creator, and contributing participant in clients' Pharmacy Oversight Committees.
Negotiates PBM and vendor contracts to maintain market competitiveness and support clients' various benefit design requests. Collaborates with Contracting to support provider contract negotiations, on-site audits, and ongoing monitoring of provider in-office dispensing practices.
Ensures the pharmacy program is prepared for audit and review, and survey and accreditation processes by external monitoring agencies, and clients with delegated pharmacy processes. Provides subject matter expertise to meaningfully participate in these audits and surveys.
Advises on the preparation of pharmacy data for use in client and provider-specific reports.
Oversees all aspects of the PBM contract for multiple clients, including coordination with client PBMs for formulary management. collaborates cross-functionally to gain results.
Oversees provider support programs and conducts site visits as necessary.
Qualification
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Required
Registered Pharmacist with a Missouri State license
15+ years of relevant experience or the knowledge, skills, and abilities to succeed in the role
7+ years in management/senior leadership or the knowledge, skills, and abilities to succeed in the role
Proven experience in a managed care setting
Expert knowledge of state and federal insurance programs
Extensive knowledge of pharmacy workflow from prescription to claims submission and authorization request processing, compliance/NCQA standards, and audit processes
Expert knowledge of budget creation/management, resource allocation, and contract/vendor management
Superb leadership skills with the proven ability to coach, develop, and motivate a large team
Excellent communication, presentation, and interpersonal skills with the ability to influence at all levels internally and externally
Outstanding project management, analytical, problem-solving, and critical thinking skills with the proven ability to identify, develop, communicate, implement, and impact process improvements and strategic initiatives
Exceptional judgment, business acumen, and collaboration skills
Distinguished ability to create results in a high-performing and high-growth environment
Preferred
Doctor of Pharmacy
Experience with Medicare Part D
Benefits
Medical
Vision
Dental
Well-being programs
401(k) with company matching
Life insurance
Paid time off including paid leave
Company
Lumeris
Lumeris is an accountable care delivery innovation company that offers operational support, technology, and consulting services.. It is a sub-organization of Essence Group Holdings.
Funding
Current Stage
Late StageTotal Funding
$325.26MKey Investors
Deerfield
2024-04-22Series A· $100M
2023-11-06Debt Financing· $50M
2016-04-01Series Unknown· $80M
Recent News
2024-11-20
2024-11-01
Fierce Healthcare
2024-05-23
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