Manager, Medical Drug Strategy & Execution

📋 Description

• • Lead the strategic development and meticulous execution of medical drug programs, with a particular focus on specialty and physician-administered drugs, ensuring all initiatives align with regulatory requirements and company vision.
• • Spearhead the implementation and operationalization of the medical drug strategy, including the comprehensive management of the pre-determination process for specialty pharmacy services.
• • Drive critical initiatives such as biosimilar adoption, the establishment of clear utilization pathways, the definition and implementation of white bagging policies, the cultivation of robust specialty pharmacy partnerships, and the development of effective sourcing strategies to optimize drug procurement.
• • Optimize the administration settings for infusion and specialty drugs, focusing on achieving significant cost savings while simultaneously enhancing patient outcomes and treatment efficacy.
• • Take the lead in executing complex CMS and state-specific drug requirements across various systems and provider networks, including the critical implementation of Part B drug provisions.
• • Champion Quality Assurance and Improvement (QAI) efforts specifically for medical drug spend and utilization, with the dual goals of supporting cost containment measures and providing accurate, consistent medical forecasting for seamless execution.
• • Foster strong interdepartmental collaboration, coordinating closely with Pharmacy, Medical, Network, Finance, and Operations teams to ensure a unified and cohesive approach to drug strategy execution.
• • Contribute to the development of integrated service delivery models designed to enhance member care and oversee the critical data and processes necessary to maintain industry-leading standards and best practices in medical drug management.
• • Support the Director in the creation and refinement of processes designed to manage the appropriate utilization of medical drugs and to ensure accurate and compliant payment for specialty and medical drug services and programs.
• • Engage proactively with providers and internal staff to ensure benefits are managed in strict alignment with all applicable regulations, including URAC and NCQA standards, as well as CareSource's overarching policies and strategic vision.
• • Oversee Continuous Quality Improvement (CQI) activities, meticulously documenting departmental processes and workflows for both internal reference and external audits, ensuring transparency and adherence to best practices.
• • Conduct thorough reviews and revisions of existing workflows to identify and implement opportunities for maximizing operational efficiencies and streamlining processes.
• • Continuously monitor productivity and utilization trends within the medical drug space, identifying key performance indicators and areas for optimization.
• • Regularly compile and report on all relevant specialty pharmacy and medical drug data, providing comprehensive program performance metrics to stakeholders.
• • Ensure strict adherence to and accurate reporting of all regulatory requirements pertaining to medical drug management and administration.
• • Analyze complex data sets related to drug utilization, spend, and outcomes, formulating data-driven recommendations for strategic adjustments and improvements.
• • Maintain and update all departmental policies and procedures, ensuring they remain current, compliant, and reflective of evolving industry standards and company objectives.
• • Serve as a key liaison with other departments, providing critical support for research initiatives and intervention strategies related to medical drug programs.
• • Perform any other job-related duties as requested by leadership, demonstrating flexibility and a commitment to the overall success of the team and organization.