Responsible for development and maintenance activities for formularies on the following lines of business: Medicare Part D, FIDA, Medicaid, Commercial, Healthcare Exchange. Responsible for rebate strategies and negotiations for the enterprise specifically for Medical Drug rebates. Interface with PBM regarding rebates for pharmacy drug claims. Responsible for the development and implementation of Healthcare Cost of Care and Medical Cost savings initiatives for the department. This includes identification, determining the savings potential by line of business with Actuary and medical economics, tracking success, and reporting. Responsible for the Academic Detailing program that are currently available in the enterprise including identifying gaps in care, improving formulary adherence, working on reporting, trending success by provider collaborative and sharing with senior leadership. Development and implementation of Medical Pharmacy initiatives including: medical prior authorizations, medical claim edits, medical drug criteria development and maintenance, site of care initiatives, preferred product determination, and rebate negotiations. Use sound clinical judgment and knowledge of regulations in ensuring compliance with regulatory and contractual obligations. Responsible for overseeing the internal UM department through 12/31/2020. After 1/1/2021, responsible for the oversight of ESI, CCUM and NCH for delivering timely, compliant, accurate coverage reviews for EmblemHealth and ConnectiCare.
• Oversee and drive pharmacy and medical drug formulary strategy for the enterprise. This entails reviewing drug trends, examining utilization management, competitor strategies, and working with internal groups (actuary, medical economics, product, and ESI) to implement formulary strategies.
• Manage the Utilization Management criteria and savings including approval and denial rates of drug classes, formulary guideline Compliance, and tracking Savings. With the Director of UM, establish an oversight dashboard and process to ensure appropriate decision making, timely for all LOBs/states and that our custom criteria is implemented accurately.
• Develop and implement medical drug strategies including but not limited to: Prior Authorization, Site of Care, medical claim edits, fee schedule, rebates, and biosimilar opportunities. Partner with network, the RPC committee, P&T Committee and provider collaboratives for implementation and monitoring. Develop and maintain a reporting dashboard for the initiatives.
• Oversee the enterprise Pharmacy cost savings initiatives strategy. This entails direct and PBM rebate contract negotiations, audits, medical pharmacy strategies, academic detailing, and utilization management. Development, implementation, and reporting by initiative, provider collaborative, and line of business to track savings estimates and trend effectiveness.
• Manage the enterprise Academic Detailing Program. This entails queue development, tracking savings, and meeting with the detailers weekly to assist with issues. Reporting should be maintained by drug, academic detailer, and provider collaborative collecting gaps detailed and success.
• Manage enterprise prior authorization criteria development including review and update of system algorithms, and Criteria for Medical Necessity (CMN) reviews for all medications to ensure alignment with formulary intent.
• Maintain clinical tools utilized by pharmacy services for purpose of remaining up to date and compliant with current pharmacy policies
• Evaluate and maintain formulary set-up based on clinical requirements, compliance with regulatory bodies, and P&T approvals. This also entails formulary monograph development, presentation at P&T Committee Meetings, annual criteria review, and website formulary and criteria postings. Serve as subject matter expert for all escalated clinical formulary related issues as well as for all formulary related internal and external audits
• Other duties/projects as assigned