Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Pharmacy UM QA Leader

📁
Director and Equivalent
📅
210CP Requisition #
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Summary of Position
•    Provide active oversight of pharmacy and medical drug UM delegates; ESI, CCUM and/or NCH.  The quality assurance process must include no fewer than 10 cases per day for the assigned delegate and a minimum of 30 overturned G&A cases per week.   
•    Identify cases with inappropriate determinations, open tickets with delegate and address timely with delegate identifying root cause, preventative measure, member and provider impact and correction.
•    Collaborate with Pharmacy Operations team to resolve operational and/or technical challenges.
•    Work closely with the formulary team to ensure appropriate criteria implementation and branching logic.
•    Establish a clinical QA methodology 
•    Work closely with the Analytics & Audit team on primary KPIs.  Investigate issues associated with KPI results. 
•    Direct the management reporting on productivity, clinical quality, compliance with state and federal pharmacy requirements and timelines.
•    Lead, develop and enforce standards of quality, quality assurance, and monitoring for the utilization management function with the assigned delegate.
•    Work with practitioners to make clinical decision trees, which will enhance the efficiency of the team.
•    Collaborate with the Medical Directors and G&A  team ensuring appropriate clinical decisions are made.

Principal Accountabilities
•    Provide active oversight of pharmacy and medical drug UM delegates; ESI, CCUM and/or NCH.  The quality assurance process must include no fewer than 10 cases per day for the assigned delegate and a minimum of 30 overturned G&A cases per week.   
Identify cases with inappropriate determinations, open tickets with delegate and address timely with delegate identifying root cause, preventative measure, member and provider impact and correction.
•    Collaborate with Pharmacy Operations team to resolve operational and/or technical challenges.
•    Work closely with the formulary team to ensure appropriate criteria implementation and branching logic.
•    Establish a clinical QA methodology 
•    Work closely with the Analytics & Audit team on primary KPIs.  Investigate issues associated with KPI results. 
•    Clinical review of ConnectiCare appeals prior to submission to IRO, effectuate authorization as appropriate.  
•    Direct the management reporting on productivity, clinical quality, compliance with state and federal pharmacy requirements and timelines.
•    Lead, develop and enforce standards of quality, quality assurance, and monitoring for the utilization management function with the assigned delegate.
•    Work with practitioners to make clinical decision trees, which will enhance the efficiency of the team.
•    Collaborate with the Medical Directors and G&A team ensuring appropriate clinical decisions are made.
•    Other duties/projects as assigned.
•    Weekend coverage for emergencies.

Education, Training, Licenses, Certifications
•    Doctor of Pharmacy degree or Masters in Pharmacy from an accredited school of pharmacy 
•    Registered Pharmacist: New York State and/or CT pharmacy license or eligible to obtain New York State license/CT state license
•    Board certification (Pharmacotherapy, Ambulatory Care, Geriatrics, Internal Medicine, Pediatrics) preferred (P)

Relevant Work Experience, Knowledge, Skills, and Abilities
•    10+ years of relevant business experience. (R)
•    A minimum of 2 years of staff and/or process management experience. (P)
•    A minimum of 5 years of pharmacist experience. (R)
•    Utilization Management experience. (R)
•    Residency or 5 years’ clinical experience. (P)
•    Knowledge of pharmaceuticals and disease states to provide advice and consultation to providers and members, and recommend changes to the formulary. (R)
•    Possess research and analytical skills sufficient to provide problem resolution and consultation to providers. (R)
•    Excellent verbal and written communication skills sufficient to prepare own correspondence and interact with members and providers in provision of advice and guidelines.  (R)

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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