Manager Pharmacy Stars and Member Outreach at Capital Blue Cross

Harrisburg, Pennsylvania, United States -

Full Time

Start Date

Immediate

Expiry Date

15 May, 26

Salary

0.0

Posted On

14 Feb, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Verbal Communication, Interpersonal Skills, Relationship Building, Collaboration, Adaptability, Prioritization, Process Improvement, Data Driven, Organizational Skills, Troubleshooting, Analytic Skills, Program Management, Strategic Mindset, Decision Making, Problem Solving, Staff Management

Industry

Insurance

Description

Position Description Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” This role is responsible for day-to-day coordination, leadership, and strategy of the Pharmacy Member Outreach arm of the Medicare Pharmacy team. This role is also responsible for the formal oversight of the PBM Care Team performance. Prioritize daily, weekly, monthly focus of PBM Care Teams and Member Outreach team. Oversight of capacity and prioritization for PBM Care Teams vs. internal team division of tasks and coordination with matrix leaders to maximize outcomes. Clear oversight and formal assessment of PBM Care Team performance and continuation of same level of support. This leader will have a customer service, process improvement, and data driven skillset and be able to interface effectively with leaders of Capital Blue Cross. The Manager reviews and updates departmental policies and procedures, monitors the performance of the pharmacy benefit manager Care Teams, manages assigned projects, establishes and monitors key performance indicators and quality controls, and assists in strategic work planning, strategic thinking, and productivity. Responsibilities and Qualifications Work with Stars Program leaders to develop and execute Stars-focused roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective. Support the creation, drive implementation, and monitoring process of the Stars Program strategy, objectives, tactics, and initiatives to drive a year over year 4+ overall Star Ratings and meeting Program goals. Drive innovative initiatives that address low-performing measures. Develop standard reports, tracking tools, metrics to monitor vendor performance, Stars/Quality measures, tactics, and initiatives. Coordinate with existing vendors, and/or implement new vendors, in order to drive desired outcomes in quality-based metrics. Gather Stars reporting data, analyze CMS changes, collaborate with Stars leads to set strategic direction. Lead and/or actively participate in meetings, workgroups, committees, etc. as Stars team expert. Collaborate in the creation, implementation and monitoring process of policies and procedures, standard operating procedures, performance guarantees and workflows to drive effectiveness, efficiency and scalability. Direct supervision and management of Pharmacy Member Outreach staff, ensuring proper application of policies and procedures and quality controls. Interface and oversee the pharmacy benefits manager (PBM) and any other related pharmacy vendors with respect to applicable Pharmacy Stars measures. Oversee pharmacy vendor Stars process(es) for effectiveness. Oversee cross-functional exchanges of information and procedural changes that impact Stars outcomes. Serve as department/business lead between pharmacy vendor(s) and internal departments to coordinate Stars needs and problem resolution. Assists in evaluating, developing, and implementing department administrative policies and procedures. Maintain appropriate staffing schedules to assure adequate coverage and workload distribution. Manage personnel issues, including hiring, training, staff performance reviews, and facilitating staff development activities. Monitor PBM performance standards and other contractual issues to assure compliance. Contributes creative solutions to improve operational efficiency and effectiveness of pharmacy team. Evaluate the effectiveness of existing metrics, developing new metrics as necessary, to better assess the performance of organization in achieving Pharmacy quality and satisfaction targets. Perform other duties as assigned. Skills: Excellent verbal communication and interpersonal skills. Able to convey complex and/or technical information in a manner that others can understand. Proven success on building and maintaining positive relationships. Exemplary of a highly collaborative team approach. Ability to influence and persuade people to collaborate and execute toward a common goal. Adaptability to an agile and dynamic work environment. Ability to prioritized tasks and shift readily between “big picture” and small-but-critical details. Demonstrated ability to balance people, process, and technology factors and analyze complex business relationships to develop appropriate solutions. Advanced proficiency in Microsoft Office applications (Outlook, Word, Excel, Power Point, etc.), Teams/WebEx/ZOOM. Strong organizational skills to manage day-to-day activities, coordinate multiple tasks, monitor and document issues/projects to ensure timely and complete resolution, and manage time effectively. Ability to troubleshoot or translate operational needs into a comprehensive action plan and take the lead in its execution. Ability to influence and persuade people to collaborate and execute toward a common goal. Significant analytic and program management skills. Strategic mindset, action and results oriented keeping the team moving forward by making good and timely decisions meeting goals and objectives. Ability to exercise sound judgment in decision-making and problem solving and handle rapidly changing priorities with minimal supervision. Ability to effectively and efficiently manage department staff, work planning, and process flow. Demonstrated initiative and take appropriate independent action. Knowledge: Have expert understanding of Star ratings and methodology applicable to Pharmacy team to inform strategic plan, drive the execution of work plan, initiatives, and overall Star performance. Managed care knowledge and experience preferred. Broad knowledge of outpatient drug benefit and utilization management programs. Knowledge of pharmacy claims processing along with applicable state/federal laws. Knowledge and experience with Medicare Part D preferred. People skills are essential that allow for the successful consultation and collaboration with internal and external stakeholders who do not directly report to this position. Adequate knowledge of health care industry issues, with excellent knowledge of health care operations and strategies. Leadership experience that demonstrates the ability to set priorities and meet objectives and execute according to plans. Knowledge of the pharmacy industry/practices, pharmacy benefit vendor, managed care principles, and prescription claims processing systems. Adequate knowledge of the Medicare Stars program, methodology, and requirements; and Medicare programs. Experience: 5 years of experience working with Medicare Advantage Plans, or managed care industry. 1 year of leadership experience, particularly in the health insurance or pharmacy benefit manager field Strong knowledge and experience working with CMS Stars Ratings measures including HEDIS, CAHPS, PQA/Pharmacy, HOS, Operations, and CMS Display measures. Experience in the coordination and collaboration of work teams preferred. Analytical skills which can translate into practical and pragmatic recommendations. Experience and knowledge in the use of Access, Tableau and/or Power BI. Experience with presentation in a variety of audiences and settings. Experience overseeing and driving Medicare Star Rating performance. Education and Certifications: Bachelor's Degree in Public Health, Health-related Sciences, or Health Administration; Business Administration, Data Analytics, Data Science, Finance, Actuarial, Mathematics or Statistics or 4 years of relevant experience in lieu of degree. Preference will be given to candidate with a relevant pharmacy related training, certification, or degree. About Us We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Responsibilities

This leadership role manages the day-to-day coordination, strategy, and performance oversight of the Pharmacy Member Outreach arm of the Medicare Pharmacy team, including formal assessment of PBM Care Team performance. Responsibilities include developing and executing a Stars-focused roadmap, driving initiatives to improve low-performing measures, and developing standard reports to monitor vendor performance and quality metrics.