Assistant Vice President, Enterprise Pharmacy Operations

Develop a strong and diverse team ensuring that all areas of pharmacy operations deliver an excellent client and member experience. Responsible for the development and implementation of all Pharmacy technology initiatives including the implementation and monitoring of FACETs transformation. Identify system and process improvement opportunities. Implement technology enhancements as needed. As the Pharmacy Government Programs Subject Matter Expert ensure all areas of pharmacy are compliant with CMS and state regulatory requirements including benefit plan design, formulary administration, coverage review processing, CMS reporting, PDE reconciliation, DIR processing and all state level reporting. Develop a Pharmacy compliance dashboard and lead the correction of all areas of improvement. Lead all Audits including CMS, State, Client, NCQA ensuring that EmblemHealth and CCI perform minimize exposure and avoid Civil Money Penalties. Manage the collection of drug and medical rebates optimizing EmblemHealth and CCI’s revenue stream. Ensure annual benefit set up is done, timely, accurately and with minimal errors. Lead the team to identify technology opportunities to reduce manual efforts and improve performance. Design solutions that deliver quality, reduced costs and improved efficiency across the enterprise. Create a culture of compliance and measurement to guide most critical initiatives to pursue. Establish quarterly scorecard reviews across the Enterprise. Support the Sales team as needed with RFP responses, participating in sales meetings with prospective clients, ensure sound underwriting through data analytics partnered with ESI. Ensure all Pharmacy communications (over 400/year) are well written, simple and sent to the targeted audience. Identify need to communicate an initiative and execute cross functionally.

Pharmacy Operations

• Ensure the integrity of benefit set up through extensive testing, both manual and automated for our more than 800 benefit groups to be set up and tested annually. Identify inaccurate test results and work with cross functional partners to correct.
• Accountable to ensure smooth implementation periods throughout the year. Through on-going measurement continue to improve the implementation process.
• Lead the development of all Pharmacy and Corporate initiatives affecting the Pharmacy department, for example the FACETs implementation, NDC JCode, etc.
• Provide direction to ESI and work closely with them in developing supporting strategies when implementing new capabilities.
• Identify opportunities for pharmacy process improvements. Work cross functionally to define comprehensive business requirements. Work closely with IT to ensure their understanding of the business process and our requirements. (example, PA Hub in CCI, ePA implementation)
• Oversee the Pharmacy Technician team supporting coverage review. Partner with the UM team to identify system improvement opportunities. Engage Prior Authorization vendor to deliver improvements.
• Implement medical drug fee schedules timely and in accordance with contracts.

Government Programs

• Ensure that our Medicare and Medicaid plans are compliant and competitively designed. Responsible to read, interpret and implement all CMS and State guidance, review with compliance and cross functional partners, define actions to be taken, implement and measure success.
• Develop a compliance dashboard, measure degree of compliance for each required process, identify opportunities for improvement and implement.
• Optimize PDE acceptance through ongoing monitoring, identify root cause of errors, work cross functionally to resolve. For example, with the Enrollment team.
• Ensure that all Acumen and/or CMS inquiries are managed timely and accurately.
• Provide legislative support and guidance regarding government affairs, actively participate in industry forums to further protect the company’s interest.
• Ensure all communications to members, providers and others are well written, easy to understand and compliant. Ensure targeted recipient definition is accurate and communications sent timely.
• Ensure all coverage review communications are compliant with CMS and state timeliness requirements and that all language is appropriate and compliant.

Quality & Safety Reporting and Audit Support

• Create a dynamic dashboard that informs the business of most effective strategies deployed and identifies risk early on such that intervention will increase success.
• Ensure all CMS submissions are timely and accurate.

Analytics, Audit & Rebates

• Establish a team of data scientists able to build informed queries in support of business strategy. For example, our stratified STARs intervention analytics.
• Create an intake process for analytic requirements reducing re-work and more quickly informing the business of key measures.
• Lead all CMS, State and internal audits. Ensure data universe is accurate. Identify key trends and opportunities by understanding the data. Work cross functionally with the pharmacy team to improve results. Drive completion of a CMS Mock audit annually.
• Deliver all government required reports including, but not limited to; PDE reconciliation, MMCOR reports, Coverage Gap Discount Reports, RDS, DIR, etc.
• Track past year pharmacy rebate collections. Work across lines to ensure that all rebates are captured and paid.
• Monitor collection of medical drug rebates, report to Sr. Leadership monthly, escalate appropriately.
• Special Projects as needed.