Responsible for developing and managing strategies to effectively facilitate and improve the company's pharmacy operation processes within the scope assigned. Primary responsibilities include Medicare and Medicaid claims review to ensure clinical appropriateness and enhanced member care. Performs utilization management activities including dose optimization and formulary management for prior authorizations and coverage determination requests. Leads teams of supervisors and is responsible for ensuring the daily production, quality, and compliance goals are met and/or exceeded.
Reports to: Director, Pharmacy
Department: Pharmacy Operations
Location: 4110 George Rd Tampa, FL 33634
Accountable for the review of Medicare and Medicaid prior authorizations and coverage determination requests to ensure the efficient delivery, clinical appropriateness, and optimization of care; including assisting in the management of work process flows.
Applies a comprehensive clinical knowledge of pharmacy claims and formularies across the lines of business. Has knowledge of all products and all types of claims.
Works closely with department leadership and Medical Directors to ensure compliance within all areas of coverage determinations.
Manages and develops direct reports who include other management or supervisory personnel and ensures the delivery of superior pharmacy operations service and member satisfaction by providing timely and accurate resolution to claims.
Develops, manages, and monitors performance for production, quality, and compliance. (i.e.: clinical criteria justifications, prior authorization / coverage determination decisions and application of department workflow processes)
Drives departmental initiatives to eliminate barriers impacting claims resolution. Works collaboratively with other leaders and departments to ensure consistency in workflow processes and that departmental goals all support the corporate goals.
Facilitates the development and implementation of department goals and performance standards.
Plans and implements strategies leading to the achievement of targeted outcomes and goals and assists in developing short range plans for the department.
Partners with department leadership to review, develop and ensure execution on departmental policies and procedures in conjunction with all state, federal, and contractual requirements and that authorization/coverage determination requests are handled within all federal and state regulatory compliance time frames.
Reviews pharmacy claims data to identify possible clinical savings opportunities.
Effectively use project plans to focus work and ensure deadlines are met; including crafting and the execution of effective AOS engagement strategies.
Lead and present at assigned committees/tasks.
Assists with coverage of night and weekend rotation as needed.
Performs special projects as assigned.
Required A Bachelor's Degree in Pharmacy
Preferred A Doctor of Pharmacy (PharmD)
Required 3 years of experience in licensed pharmacist role or successful completion of a PGY-1 Residency Program
Required 1 year of management experience Required Other Experience in managed careCandidate Skills:
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated written communication skills
Intermediate Ability to influence internal and external constituents
Intermediate Other Ability to use pharmaceutical and medical reference, literature to provide drug information to the health plan
Intermediate Other Ability to evaluate financially the impact of drug products
Intermediate Ability to communicate and make recommendations to upper management
Intermediate Ability to lead/manage others in a matrixed environment
Intermediate Knowledge of healthcare delivery
Intermediate Ability to create, review and interpret treatment plans
Licenses and Certifications:
A license in one of the following is required:
Required Other Licensed pharmacist in state of operation
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Word
Required Intermediate Microsoft PowerPoint
Required Intermediate Microsoft Outlook
About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.