Capital Blue Cross · 7 hours ago
Manager Pharmacy Member Outreach
United States
Full-time
Remote
Mid, Senior Level
$84K/yr - $158K/yr
5+ years expCapital Blue Cross is committed to improving the health and well-being of its members and communities. The Manager Pharmacy Member Outreach is responsible for the coordination and leadership of the Pharmacy Member Outreach team, overseeing performance and developing strategies to enhance the quality of pharmacy services and outcomes.
ConsultingHealth CareHealth InsuranceProfessional Services
Responsibilities
Responsible for day-to-day coordination, leadership, and strategy of the Pharmacy Member Outreach arm of the Medicare Pharmacy team
Responsible for the formal oversight of the PBM Care Team performance
Prioritize daily, weekly, monthly focus of PBM Care Teams and Member Outreach team
Oversight of capacity and prioritization for PBM Care Teams vs. internal team division of tasks and coordination with matrix leaders to maximize outcomes
Clear oversight and formal assessment of PBM Care Team performance and continuation of same level of support
Develop and execute Stars-focused roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective
Support the creation, drive implementation, and monitoring process of the Stars Program strategy, objectives, tactics, and initiatives to drive a year over year 4+ overall Star Ratings and meeting Program goals
Drive innovative initiatives that address low-performing measures
Develop standard reports, tracking tools, metrics to monitor vendor performance, Stars/Quality measures, tactics, and initiatives
Coordinate with existing vendors, and/or implement new vendors, in order to drive desired outcomes in quality-based metrics
Gather Stars reporting data, analyze CMS changes, collaborate with Stars leads to set strategic direction
Lead and/or actively participate in meetings, workgroups, committees, etc. as Stars team expert
Collaborate in the creation, implementation and monitoring process of policies and procedures, standard operating procedures, performance guarantees and workflows to drive effectiveness, efficiency and scalability
Direct supervision and management of Pharmacy Member Outreach staff, ensuring proper application of policies and procedures and quality controls
Interface and oversee the pharmacy benefits manager (PBM) and any other related pharmacy vendors with respect to applicable Pharmacy Stars measures
Oversee pharmacy vendor Stars process(es) for effectiveness
Oversee cross-functional exchanges of information and procedural changes that impact Stars outcomes
Serve as department/business lead between pharmacy vendor(s) and internal departments to coordinate Stars needs and problem resolution
Assists in evaluating, developing, and implementing department administrative policies and procedures
Maintain appropriate staffing schedules to assure adequate coverage and workload distribution
Manage personnel issues, including hiring, training, staff performance reviews, and facilitating staff development activities
Monitor PBM performance standards and other contractual issues to assure compliance
Contributes creative solutions to improve operational efficiency and effectiveness of pharmacy team
Evaluate the effectiveness of existing metrics, developing new metrics as necessary, to better assess the performance of organization in achieving Pharmacy quality and satisfaction targets
Perform other duties as assigned
Qualification
Required
5 years of experience working with Medicare Advantage Plans, or managed care industry
1 year of leadership experience, particularly in the health insurance or pharmacy benefit manager field
Strong knowledge and experience working with CMS Stars Ratings measures including HEDIS, CAHPS, PQA/Pharmacy, HOS, Operations, and CMS Display measures
Excellent verbal communication and interpersonal skills
Proven success on building and maintaining positive relationships
Ability to influence and persuade people to collaborate and execute toward a common goal
Adaptability to an agile and dynamic work environment
Ability to prioritize tasks and shift readily between 'big picture' and small-but-critical details
Demonstrated ability to balance people, process, and technology factors and analyze complex business relationships to develop appropriate solutions
Advanced proficiency in Microsoft Office applications (Outlook, Word, Excel, Power Point, etc.), Teams/WebEx/ZOOM
Strong organizational skills to manage day-to-day activities, coordinate multiple tasks, monitor and document issues/projects to ensure timely and complete resolution, and manage time effectively
Ability to troubleshoot or translate operational needs into a comprehensive action plan and take the lead in its execution
Significant analytic and program management skills
Strategic mindset, action and results oriented keeping the team moving forward by making good and timely decisions meeting goals and objectives
Ability to exercise sound judgment in decision-making and problem solving and handle rapidly changing priorities with minimal supervision
Ability to effectively and efficiently manage department staff, work planning, and process flow
Demonstrated initiative and take appropriate independent action
Have expert understanding of Star ratings and methodology applicable to Pharmacy team to inform strategic plan, drive the execution of work plan, initiatives, and overall Star performance
Broad knowledge of outpatient drug benefit and utilization management programs
Knowledge of pharmacy claims processing along with applicable state/federal laws
Adequate knowledge of health care industry issues, with excellent knowledge of health care operations and strategies
Leadership experience that demonstrates the ability to set priorities and meet objectives and execute according to plans
Knowledge of the pharmacy industry/practices, pharmacy benefit vendor, managed care principles, and prescription claims processing systems
Adequate knowledge of the Medicare Stars program, methodology, and requirements; and Medicare programs
Bachelor's Degree in Public Health, Health-related Sciences, or Health Administration; Business Administration, Data Analytics, Data Science, Finance, Actuarial, Mathematics or Statistics or 4 years of relevant experience in lieu of degree
Preferred
Managed care knowledge and experience preferred
Knowledge and experience with Medicare Part D preferred
Experience in the coordination and collaboration of work teams preferred
Experience and knowledge in the use of Access, Tableau and/or Power BI
Experience overseeing and driving Medicare Star Rating performance
Benefits
Medical, Dental & Vision coverage
Retirement Plan
Generous time off including Paid Time Off
Holidays
Volunteer time off
Incentive Plan
Tuition Reimbursement
Company
Capital Blue Cross
At Capital Blue Cross, we promise to go the extra mile for our team and our community.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Todd Shamash
President and CEO
Glenn Heisey
Executive Vice President and Chief Operating Office
Recent News
2025-10-02
2022-10-14
Company data provided by crunchbase