Sr. Health Plan Pharmacist

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.  

This position is responsible for assisting the Health Plan Pharmacy Services department in all areas including but not limited to: Pharmacy Operations, Clinical Pharmacy Quality Initiatives, Pharmacy oversight and audits and Health plan reporting.

Part D activities related to formulary management, coverage decisions, pharmacy benefit management, pharmacy claims processing and monitoring functions that help ensure the department is in compliance with CMS standards. This position will also assist with administrative clinical pharmacy activities deemed necessary for Kelsey-Seybold Clinic and drug trend management

Primary Responsibilities:

• Formulary and Utilization Management
  • Maintain and monitor Medicare Part D formularies, including updates, HPMS submissions, adjudication system coding, member materials, and notifications
  • Align formulary and drug coverage decisions with clinical guidelines and regulations by conducting drug utilization reviews and monitoring industry trends
  • Review prescribing trends to ensure alignment with health plan formularies and cost-effective treatment strategies
  • Conduct and validate formulary and transition coding, testing, and disruption analysis; resolve errors with PBM and internal departments
  • Ensure formulary decisions support company goals and collaborate with other departments to align with business strategy
• Coverage Determination, Direct Member Reimbursement and Redetermination (CDR) Oversight
  • Ensure timely, accurate, and compliant coverage determinations, reimbursements, and appeals; validate CDR reportable data
  • Resolve decision-making errors with PBM and internal departments; serve as the CDR subject matter expert
• Part D Benefit Administration
  • Conduct benefit testing and review production claims to ensure compliance with CMS requirements
  • Review retrospective eligibility adjustments for payment accuracy.
  • Administer new regulatory requirements and resolve adjudication errors with PBM and internal departments
• Fraud, Waste and Abuse (FWA)
  • Implement CMS Drug Management Program activities, monitor at-risk beneficiaries, and ensure compliance with OIG requirements
  • Review FWA reports, perform audits, investigate potential FWA cases, and report to CMS as needed
• Compliance with Regulatory Requirements
  • Understand CMS regulations and requirements, monitor communications and legislative developments, and analyze their impact
  • Communicate internal monitoring activities with the compliance team and support leadership in CMS reporting and audits
• First-tier, Downstream or Related Entity (FDR) Performance Oversight
  • Oversee PBM and vendor performance to ensure contract and CMS requirements are met
  • Track, reconcile, and report FDR performance, identify deficiencies, and ensure timely communication of tasks and expectations
• Prescriber, Pharmacy, Intra and Interdepartmental Communication
  • Update educational materials for KCA and KSC teams, communicate formulary updates, and implement health plan medication initiatives
  • Provide administrative and clinical support for committees and attend meetings; document and follow up on action items
• Health Plan Clinical Consultant
  • Respond to inquiries from pharmacies, members, and representatives regarding pharmacy claims and benefit questions
  • Conduct clinical reviews of medications, identify cost-effective alternatives, and provide patient counseling and medication reconciliation
• Plan Mandated Materials
  • Develop accurate marketing documents and Part D Model Materials, including formularies, directories, EOBs, and coverage criteria
  • Review Medicare Prescription Payment Plan materials and prepare AEP training documents for member services and marketing teams
• Health Plan Pharmacy Services Training and Support
  • Develop and maintain Part D policies, procedures, workflows, and action plans
  • Support technical staff, pharmacy residency program, and intern education and training
  • Provide administrative and clinical support for special projects and adhere to pharmacy laws
    

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. 

Required Qualifications:

• Pharm D. degree            
• Completion of an accredited ASHP/AMCP Managed Care Pharmacy Residency Program (PGY1) OR 2 years HMO 3rd party managed care experience OR 2 years operational pharmacy benefit experience
• Current and Active Pharmacy License
• Texas State Board of Pharmacy Registered Pharmacist
• Solid communication skills with personnel, members, and healthcare providers for delegation, training, claims approval, complaint resolution, medication recommendations, and education
• Ability to write reports, create policies, procedures, work guides, and training documents
• Excellent alpha/numeric data entry skills with minimal errors
• Proficiency in Microsoft Word and Excel
• Multitasking, problem-solving, and analytical skills
• Detail-oriented with good verbal and written communication, interpersonal skills, professional appearance, and ability to work in a fast-paced environment
• High stress tolerance to ensure accurate pharmacy benefit administration approved by CMS
  

Preferred Qualifications:

• Medicare Part D experience
• Auditing experience
• Customer Service experience
• Proficient in RxClaim or other claims adjudication systems and EPIC
• Professional Appearance

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $112,700    to $193,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.