AmeriHealth Caritas Manager - Formulary Management and Drug Utilization Review in Philadelphia, Pennsylvania

Manager - Formulary Management and Drug Utilization Review

Location: Philadelphia, PA

Telecommuter?: Yes

ID**: 14232

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .

Responsibilities:

  • Oversees the day-to-day clinical operations of PerformRx Clinical Operations, by working closely with the formulary clinical Pharmacists and Technicians to ensure compliance with all formulary policy and procedures.

  • Oversees the development of specialty medication clinical initiatives and prior authorization criteria.

  • Manages the development and production of clinical materials for formulary reviews and P&T committee meetings. This includes but not limited to preparing clinical literature overview, claims analysis, value comparisons, utilization projections, and therapeutic class overview.

  • Manages the transition of new clients over to PerformRx formulary and maintains formulary compliance and adherence.

  • Collaborate with PerformRx Compliance Integrity/Quality Assurance Department, corporate compliance and health plan client regulatory affairs to ensure programs meet HIPAA, URAC, regulatory, and/or CMS requirements in regards to process, documentation, communication and reporting.

  • Oversees the clinical editing for claims processing system as well as overseeing the efforts of benefit design, administrative/clinical edits, and step therapy protocols for all new business implementations.

  • Participate in P&T meetings including client on-site meetings.

  • Supervises the tracking and establishment of trend analysis on physician requests. Monitors utilization data on drugs requiring prior approvals. Facilitates the research necessary to maintain assigned program detail, including therapeutic category and comparative drug review. Provides background research, analysis and prepares statistical trend information on specific drugs.

  • Keeps abreast of industry trends and regulatory changes in the pharmacy industry and evaluates their effect on pharmacy contracts and services. Makes recommendations on program improvements, based on findings and utilization.

  • Review requested information for audits and forward information to Compliance Integrity/Quality Assurance Department

  • Takes active role in reviewing and responding to RFP’s in conjunction with other departments when called upon

  • Troubleshoot operational aspects of the department

  • Travel as needed to support any Formulary related functions such as but not limited to Pharmacy and Therapeutics Committee meetings, client reviews and sales and marketing presentations

  • Provides daily support for specialty medication clinical initiatives

  • Manages specialty clinical staff to ensure all tasks are completed

  • Manage and audit direct reports as well supporting Technicians and Pharmacists to ensure accuracy and productivity in day-to-day operations are maintained

  • Supports Fraud and Abuse program system oversight. Communicates any suspected fraud discovered by department staff. Recommends course of action for providers where patterns appears outside of guidelines and generally accepted pharmacy standards.

Education/Experience:

  • Bachelor’s Degree in Pharmacy

  • R.Ph. or Pharm.D. required

  • Minimum two (2) years of current project and/or staff management experience required

  • Minimum three (3) years of pharmacy experience required

  • Current Pharmacy license required; state of PA preferred

  • Current/previous experience in managed care environment required

  • Ability to quickly troubleshoot concerns of members/providers and handle escalated situations

  • Ability to collaborate inter and intra departmentally

  • Ability to handle multiple priorities and projects independently

  • Ability to interface with all levels of management

  • Ability to professionally and credibly articulate sound clinical arguments

  • Ability to quickly troubleshoot concerns of members/providers and handle escalated situations

  • Demonstrate ability to effectively motivate and manage a team

  • Excellent verbal and written communication skills

  • Proficient PC skills in a Windows based environment

  • Proven ability to write technical articles, position papers and draft presentation documents

  • Strong clinical knowledge and the ability to make sound clinical judgments

  • Strong presentation, organizational, problem-solving, and time management skills

EOE Minorities/Females/Protected Veterans/Disabled