Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY
The Clinical Pharmacy Program Manager provides highly specialized integrated clinical pharmacy services to the health plan. This position is responsible for managing both clinical and operational functions for pharmacy benefit administration for the assigned line of business. The Clinical Pharmacy Program Manager will be responsible for supervising clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Review medical and pharmacy benefit claims data for trends and outliers to identify opportunities to enhance medication UM strategies on high-cost drugs, formulary strategies, and Fraud, Waste, Abuse (FWA) reporting, lead Complex Medication Management program initiatives
Perform utilization management review of drug requests as assigned, including but not limited to prior authorization review, appeals, non-formulary exception and override requests
Analyze utilization and prior authorization data to identify drug utilization trends and cost-savings opportunities
Conduct oversight over prior authorization criteria and delegated utilization management functions performed by PBM
Serve as clinical resource supporting Care Management, Service Coordination, and Utilization Management functions on medication-related projects and inquiries
Manage the Medication Therapy Management (MTM) program
Supervise clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned
Actively contributes to achievement of departmental goals, including specific departmental process improvement plans, and other duties as assigned.
Review medical and pharmacy benefit claims data for trends and outliers to identify opportunities to enhance medication UM strategies on high-cost drugs, formulary strategies, and Fraud, Waste, Abuse (FWA) reporting, lead Complex Medication Management program initiatives
Perform utilization management review of drug requests as assigned, including but not limited to prior authorization review, appeals, non-formulary exception and override requests
Analyze utilization and prior authorization data to identify drug utilization trends and cost-savings opportunities
Conduct oversight over prior authorization criteria and delegated utilization management functions performed by PBM
Serve as clinical resource supporting Care…