Capital Blue Cross · 10 hours ago
Manager Pharmacy Stars and Member Outreach
United States
Full-time
Remote
Senior Level
5+ years expCapital Blue Cross is committed to enhancing the health and well-being of its members and communities. This role is responsible for the coordination, leadership, and strategy of the Pharmacy Member Outreach arm of the Medicare Pharmacy team, overseeing performance and ensuring effective operations to meet program goals.
ConsultingHealthcareHealth InsuranceProfessional ServicesHealth Care
Responsibilities
Work with Stars Program leaders to 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
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
Excellent verbal communication and interpersonal skills. Able to convey complex and/or technical information in a manner that others can understand
Proven success on building and maintaining positive relationships. Exemplary of a highly collaborative team approach
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
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
Preferred
Managed care knowledge and experience preferred. Broad knowledge of outpatient drug benefit and utilization management programs
Knowledge of pharmacy claims processing along with applicable state/federal laws. Knowledge and experience with Medicare Part D preferred
Experience in the coordination and collaboration of work teams preferred. Analytical skills which can translate into practical and pragmatic recommendations
Experience and knowledge in the use of Access, Tableau and/or Power BI
Experience with presentation in a variety of audiences and settings. Experience overseeing and driving Medicare Star Rating performance
Preference will be given to candidate with a relevant pharmacy related training, certification, or degree
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
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