It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Reporting to the Senior Manager ofPharmacy Operations, the Manager of Clinical Pharmacy Operations is primarily responsible for the oversight of the daily operations of the Pharmacy Operations Clinical Pharmacists. The Manager of Clinical Pharmacy Operations will oversee the day-to-day responsibilities of the Clinical Pharmacists, activities related to pharmacy utilization management (UM) program, review of all pharmacy prior authorization requests, and maintenance of existing pharmacy UM programs. In addition, the Manager of Clinical Pharmacy Operations will assist with pharmacy utilization management and clinical policy implementation, developing training for the Clinical Pharmacists, and performing quality assurance analyses ensuring compliance with regulatory and accreditation requirements.

Our Investment in You:

• Full-time remote work

• Competitive salaries

• Excellent benefits

Key Functions/Responsibilities:

• Supervises all Pharmacy Operations Clinical Pharmacists
• Oversee the day-to-day responsibilities of the Clinical Pharmacists, including the prior authorization activities for both pharmacy and medical benefits
• Monitor pharmacy operation performance metrics to ensure compliance with performance thresholds in accordance with regulatory, contractual and accreditation requirements
• Responsible for staff management, including individual monitoring and reporting of performance metrics for the Clinical Pharmacists and ensuring staff performance meets expected thresholds
• Documents overall evaluation scores and identifies key recurring issues across the department
• Conduct regular quality assurance analyses of UM to ensure decisions are appropriate, consistent and aligned with covered benefits, clinical policies, medical necessity and inter-rator reliability
• Conducts needs assessments, tracks trends through call monitoring scores and partners with the leadership team to identify training and coaching opportunities for staff at all levels.
• Oversee operations processes relevant to the administration of the pharmacy utilization management program, including, but not limited to effectuation of authorizations, resolving claims adjudication issues, crossover of claims between pharmacy and medical benefits
• Provides continuous review and enhancement of established customer service and Provider/member/pharmacy interactions to ensure all interactions are aligned with Health Plan customer service metrics. Recommends modifications where appropriate.
• Hire, orient and provide supervision, continued education/training, performance evaluation and professional development to the Clinical Pharmacists
• Participate in the development and design of drug utilization programs and new clinical program opportunities
• Collaborate with other pharmacy department colleagues to assist with formulary and clinical program initiatives, as needed
• Manages the operations Clinical Pharmacist team through performance metrics and evaluations.
• Facilitates regular team meetings and one on one coaching sessions with team.
• Responsible for performance appraisals of all direct reports.
• Meets regularly with team to identify challenges and barriers to success
• Coaches team on professional development and areas of growth.
• Direct supervision exercised of 8 or more direct reports

Qualifications:

• Must be experienced with tools and templates used for tracking, distributing and monitoring work deliverables.
• Superior organizational and communications skills, both verbal and written.
• Excellent interpersonal skills and communication skills to succeed in a cross-functional, matrixed environment required.
• Strong organizational and time management skills, including ability to work independently and prioritize multiple projects and assignments in a fast-paced environment.
• Process-oriented and can accomplish tactical deliverables and meeting deadlines.
• Flexible, team-player approach to goal setting and attainment.
• Self-motivating, able to assume responsibility and work autonomously in a professional manner.
• Demonstrated strength in analysis, identification of problems and issue resolution
• Must be results and detail oriented

Education & Experience:

• Bachelor of Science in Pharmacy, Doctor of Pharmacy preferred
• Current unrestricted licensure as a pharmacist in the Commonwealth of Massachusetts or other U.S. state
• 5 years of Clinical experience, required
• 2+ years of prior managed care experience, preferred
• 2+ years of prior management/supervisory experience, required
• Extensive knowledge of drug products, medical therapeutics, pharmacokinetics, and disease states.
• Experience with standard Microsoft Office applications, particularly MS Outlook and MS Word, and other data entry processing applications
• Strong analytical and clinical problem solving skills.
• Proficiency in standard computational office-suite applications, including Word, Excel, PowerPoint, Sharepoint, and Outlook required.
• Occasional travel (<5%) may be required
• Remote position

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.