Director, Clinical Services

Summary

Engage in and provide expertise in various pharmacy benefit management activities which include, but are not limited to, utilization management, prior authorization reviews, benefit design, and clinical account management.

 Role and Responsibilities

• Good understanding of medications’ use and application to disease states and conditions to provide qualified clinical decision making during the prior authorization review process.
• Operationalize procedures for appropriate and effective medication prior authorization clinical reviews.
• Manage and support prior authorization triage team members to support medication prior authorization clinical service.
• Communicates effectively in peer-to-peer discussion with prescribers related to prior authorization reviews.
• Monitor and provide oversight of IPM’s pharmacy benefit and formulary set-up/maintenance.
• Provide analysis of drug utilization and make recommendations in quarterly summary reports.
• Provide clinical account management role by presenting drug utilization analysis and trends to clients during client quarterly meeting presentations.
• Identify and assess opportunities to improve surveillance of vendor obligations and performance through data and/or systems.
• Understands contemporary health system services and enterprise pharmacy service needs (e.g. MTM and patient management, population for specialty focus, etc.) and facilitates implementation of these services.
• Work with teams through the assessment, problem definition, solution development, issue and risk identification/mitigation, and work plan development to ensure quality results that exceed our client’s expectations.
• Provide analysis of paid and rejected pharmacy claims to ensure they are adjudicating according to intended pharmacy benefit design.
• Support all non-financial audits as required (SOX, CMS/State, internal).
• Provides input on additions, deletions, preferred drug determinations, therapeutic substitutions for needed modifications to the company's formulary.
• Must possess excellent oral and written communication skills, demonstrate leadership, strong interpersonal skills and can perform analyses related to opportunities in the pharmacy.
• Ability to develop medication monographs and appropriate and effective prior authorization criteria.
• Support sales team’s in presenting clinical programs and initiatives to potential clients.
• Assist with analysis and provide responses to Request for Proposals (RFPs) questions.
• Other duties as assigned/required.

Knowledge and Skills Required

• Good understanding of contemporary health system services and define enterprise pharmacy service needs (e.g. MTM and patient management, population for specialty focus, etc.) and see these services through to implementation.
• Strong conceptual, as well as quantitative and qualitative, analytical skills
• Ability to trouble shoot data and direct analysts in analyzing complex data sets
• Ability to effectively interface and collaborate with health system, pharmacy and third-party payor department directors.
• Flexibility and responsiveness in managing multiple projects in sometimes high-pressure situations simultaneously
• Self-motivator with ability to work independently
• Plan, direct, and coordinate work activities of others

PHYSICAL REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

This is a largely sedentary role; however, some standing, walking, bending, and reaching may be required.  Regularly operates a computer, mouse, keyboard, and occasionally operates other standard office equipment, such as printer, copier, phone.