Principal Clinical Leader

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.This is a fully remote, work from home role. The ideal candidate will reside in the state of Kentucky.Position Summary

The Pharmacy Director for Aetna Better Health of Kentucky will be responsible for all clinical, financial, operational and compliance activities related to the prescription drug benefit for the Plan.The Pharmacy Director is an integral member of the health plan executive leadership team (CEO, COO, CMO, CFO, Legal, and Actuarial) providing leadership, analysis, and guidance to the health plan and external partners for the state Managed Medicaid pharmacy benefit. The Pharmacy Director reports to the Senior Lead Pharmacy Director and holds an organizational chart dotted line directly to each respective Health Plan Line of Business CEO or CMO. The role of the Pharmacy Director is to oversee and manage all financial and operational aspects of pharmacy and prescription drug services within the Kentucky Medicaid health plan and to execute the Pharmacy Benefit in accordance with all statutes, regulations, and contractual requirements. This position plays a critical role in ensuring the safe, effective, and efficient use of medications for plan members.What you will do

• Strategic Planning: The Pharmacy Director develops and implements strategic plans for pharmacy services that align with the organization's goals and objectives. This involves identifying opportunities for improvement, setting performance metrics, and establishing long-term strategies to promote the quality of pharmaceutical care in a cost-effective manner to establish a competitive advantage for the health plan.

• Pharmacy Benefit Management: The Pharmacy Director is responsible for managing the pharmacy benefit program offered by the health plan. This includes benefit set-up, claims processing, contractual oversight, formulary management and updates, medication utilization review, prior authorization processes in alignment with contract, and implementing cost-effective drug utilization initiatives.

• Regulatory Compliance: The Pharmacy Director ensures compliance with state and federal statutes and regulations pertaining to both pharmacy practice laws and Managed Medicaid/PBM regulations. The Pharmacy Director stays updated on changing regulations, implements necessary changes, and ensures adherence to requirements such as drug pricing transparency, medication safety, and controlled substance regulations. The Pharmacy Director is expected to attend and lead discussions as the delegated health plan representative in all state meetings regarding pharmacy program initiatives, new legislation, Drug Utilization Review (DUR) and formulary/guideline changes.

• Provider and Vendor Management: The Pharmacy Director collaborates with pharmacy network providers, including retail pharmacies, mail-order pharmacies, and specialty pharmacies to ensure contracts are compliant with state regulations, monitor reimbursement rates, and maintain positive working relationships. The Pharmacy Director collaborates with Provider Relations to create single case agreements to ensure member access to medically necessary services. Additionally, the Pharmacy Director manages relationships with pharmacy benefit managers (PBMs) and other vendors to optimize medication access and cost management.

• Clinical Pharmacy Programs: The Pharmacy Director oversees the development and implementation of clinical pharmacy programs aimed at improving patient outcomes and medication safety. This may involve medication therapy management (MTM), disease management initiatives, drug utilization review, and medication adherence programs.

• Quality Assurance and Patient Safety: The Pharmacy Director establishes and maintains quality assurance programs to ensure the safe and effective use of medications. This includes monitoring medication errors, adverse drug events, and implementing strategies to minimize risks. They may also collaborate with other departments to develop and implement patient safety initiatives that align with HEDIS measures.

• Financial Management: Managing the pharmacy budget is an important aspect of the role. The Pharmacy Director works closely with the Chief Financial Officer (CFO) and Actuary team to develop and monitor budgets, analyze financial data, identify cost-saving opportunities, and optimize medication-related expenditures.

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.