Quality and Compliance Pharmacist - Aspire Health Plan

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Job Description:

Company Overview

Aspire Health Plan is a locally owned Medicare Advantage HMO that provides comprehensive medical coverage to seniors and other Medicare recipients in Monterey County. We’re proud to be a community-centered organization backed by Montage Health and Salinas Valley Memorial Health System. Over 700 doctors, many other healthcare providers, and all four Monterey County hospitals are part of the Aspire Health Plan network. It’s the care you need from people you know.

Purpose of Position

Under the leadership of the Director of Pharmacy, this position will manage quality improvement projects for the Medicare Advantage population and work cross-functionally across the pharmacy team to support compliance and utilization management. The pharmacist will be responsible for processes related to medication safety and adherence, Part D star measure improvement, and member outreach to resolve problems in accessing Part D benefits. Since most Part D services are delegated to vendors or providers partners, this position requires strong communication skills to minimize member and provider abrasion. The pharmacist will function as a subject matter expert on Medicare prescription drug coverage and is responsible for supporting pharmacy vendor relationships, customer service, and population health teams.

The pharmacist is responsible for the daily oversight and execution of the pharmacy quality programs impacting Stars, Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and other programs as necessary. Responsibilities include day-to-day management of existing programs and the development, implementation and management of new programs focused on quality initiatives. The pharmacist will be responsible for managing pharmacy quality program vendors delegated for medication therapy management (MTM) services and medication adherence outreach. This position will facilitate collaboration with internal stakeholders to ensure that Stars initiatives are fully integrated throughout the organization. This position includes partnership with Aspire’s Quality department to coordinate communication with external provider groups and supporting other Aspire departments with clinical programs cross-functionally aimed at improving quality measures and/or compliance requirements. This position will also assist in the preparation of reports, coverage determinations, and utilization management for Part B and Part D.

The ideal candidate is a self-starter, enjoys solving challenging problems, uses data to drive insights, and excels in a fast-paced environment. It is preferred for the candidate to live locally, however, a remote position may be considered with the ability to travel to Monterey quarterly for on-site meetings.

Responsibilities

Utilization Management

• Perform utilization management and daily operational activities such as reporting and monitoring to assist pharmacy team across all lines of business.

• Participate in Medicare Part D provider education training and assist with communications.

Compliance

• Assist the Director with the Centers for Medicare and Medicaid Services (CMS) audit reports and provide Medicare Part D regulatory, clinical and formulary inquiry support for internal staff and external stakeholders.

• Review and monitor Pharmacy Benefit Manager (PBM) formulary submissions and updates for compliance with CMS formulary rules.

Quality

• Serve as a subject matter expert for CMS Medicare Advantage Stars and manage quality reporting and analytical strategies to enable accountable entities and stakeholders to drive quality ratings improvement for CAHPS, Health Outcome Survey (HOS), HEDIS, Medication Adherence and Plan Operations. 

• Serve as a subject matter expert in the management of specified pharmacy quality measures by monitoring/tracking quality intervention and analytical strategies that elevate quality of care and enhance satisfaction for members, including but not limited to: 

• Performing deep dive root cause analyses, strategizing, identifying opportunities, and implementing initiatives to achieve results for pharmacy quality programs and member experience in accessing their Part D services including MTM, medication adherence, medication reconciliation, and other programs.

• Monitoring quality measure to achieve high performance and developing strategy, processes, and program implementation to improve Medicare Star Ratings quality metrics, medication or medical issues and cost containment which may involve managing call campaigns, partnering with vendors, or creating educational materials for members and providers.

• Developing and maintaining monthly/weekly reporting of performance regarding activities, programs, and performance expectations as related to tasks.

• Analysis and reconciliation of Part D claims compared to PDEs. Review of available Part D data sources for opportunities to improve member experience, medication adherence, or plan design. Identify potential obstacles to care along with opportunities for improvement.

• Support annual HEDIS audit, as needed.

• Investigate questions/issues escalated from care teams. Outreach members to assist in resolving issues with Part D.

• Development of internal and external education and training for Part D quality programs and metrics.

• Interface with Providers, pharmacies, members, and other stakeholders as needed to achieve qualitive initiatives, Star measure improvement, or FWA indicators for Medicare programs.

Vendor Management

Assist Director of Pharmacy in the following vendor activities:

• Management account calls and deliverables for Part D quality vendor (MTM outreach and medication adherence), including MTM program submission to CMS.

• Monitor daily issue/response files with PBM for claim resolution and outreach PBM for refills, claim reprocessing, and to members to provide status of intervention.

• Oversight of PBM, including but not limited to, ensuring that the review, coding, and quality control of formulary changes occur in an appropriate, accurate, and timely manner.

Performs all other miscellaneous responsibilities and duties as assigned or directed.

Experience/Skill Set

• 3+ years of Medicare Advantage Part D experience, CMS Star rating program specifications

• Experience in implementing initiatives to improve quality ratings and managing projects and programs.

• Organizes workload, sets priorities, completes assignments in a timely manner and utilizes resources appropriately while complying with department program standards.

• Knowledge of and high proficiency with Microsoft Office Suite such as Outlook, Access, Excel and Word

• Strong communication skills both written and verbal

Education/Licensure

• Graduate of an accredited School of Pharmacy with a current and unrestricted California State Pharmacy License

Competencies

• Accountability and Dependability: Assumes responsibility for accomplishing duties in an effective and timely manner.

• Integrity:  Consistently honors commitments and takes responsibility for actions and words. 

• Software and Computer Skills: Proficient in the use of Microsoft Office Suite, highly skilled at using the Internet. Must learn effectively with computer-based and/or online training.

• Flexibility:  Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.

• Inclusiveness:  The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.

Salary - $140,000 annually

Equal Opportunity Employer

Assigned Work Hours:

Full-time (Exempt)

Position Type: