Administration - Vice President of Medicare & Quality Strategy
The Vice-President, Medicare and Quality Strategy is accountable to ensure all fundamental Pharmacy Benefit Management (PBM) components required to operate a highly successful Medicare Advantage Prescription Drug (MAPD) Program are in place to support a successful go-to-market launch and scalable for growth in this market. This executive leader will collaborate both inside Pharmastar (PBM Clinical Services, PBM Operations, etc.) and across the Tabula Rasa HealthCare enterprise (Quality, Compliance, MTM services, MedWise Medication Risk Reduction) to leverage expertise, knowledge and services that will differentiate our Medicare offering in the marketplace and propel future growth in our target market of start-up MAPD plans, Institutional Special Needs Plan (ISNP) and Dual Eligible Special Needs Plans (DSNPs). In addition, the leader will provide Medicare expertise and consultation (beyond Pharmastar) to assist other TRHC businesses that are critical to the success of our overall Medicare strategy (i.e., MTM service business excellence, MedWise Medication Safety Review impact on STARS, etc.). Finally, this executive leader will serve as our enterprise Quality and Safety Officer forming an Enterprise Quality and Safety Counsel responsible for charting the strategy to measure and report on metrics that matter most to our clients in demonstrating our excellence in patient safety and quality.
- Collaborate with BluePeak to identify the gaps in the current PBM business model required to support MAPD.
- Develop plans of action for each gap and scale appropriately for projected business growth.
- Collaborate with PBM operations to enhance current PACE call center with Medicare talent, expertise and training.
- Collaborate with PBM clinical operations to license a Coverage Determinations Grievance and Appeals system and determine the best staffing model.
- Collaborate with enterprise analytics to enhance reporting capabilities to support Medicare requirements.
- Solidify a Medicare compliance strategy in collaboration with Chief Compliance Officer, TRHC to address potential violations of Compliance, FWA and Security.
- Collaborates with Compliance and Policy Committee to coordinate the policy review and approval process, identification and resolution of recent regulatory notices or potential instances of non-compliance.
- Build programs to support CMS Quality Rating System to support revenue and membership growth.
- Responsible for Quality Improvement Programs related to Medicare Part D.
- Responsible for STAR Rating Program.
- Monitors federal notices and call letters to identify program development needs.
- Leads clients and internal partners to understand the implications of program developments and new regulatory requirements.
- Prepare executive level material to showcase the evaluation of strategies and investments needs to solidify decisions to close the gaps to support Medicare.
- Develop an understanding of our first start-up MAPD client and supply both Medicare health plan and Medicare PBM expertise.
- Ensure client satisfaction resulting in engagement, retention, and client referrals.
- Ensure an effective Fraud Waste and Abuse program is in place including investigations, reporting, and training to meet Chapter 9 and Health Care Reform requirements.
- Ensure that first tier entities, downstream entities and related entities are aware of and follow the applicable Government Program requirements.
- Enhance and ensure competitiveness of our Medicare proposal, pricing structure and contract.
- Collaborate with clinical strategy, operations strategy and client development to determine the client support model (Account Manager, Clinical Pharmacy Manager, etc.) and hiring plan for Medicare.
- Demonstrates leadership while integrating other Tabula Rasa HealthCare services.
- Identifies prospective Medicare clients for the sales pipeline.
- Assists with Medicare client renewals, upsells, cross-sells and with securing new clients.
- Guides and provides feedback to teams supporting Medicare ensuring timely, accurate and credible responses to clients.
- Leverages Tabula Rasa HealthCare’s clinical and medication safety offerings to improve client member outcomes.
- Collaborates with Pharmastar Audit support to ensure Medicare expertise and that clients are supported and experience a smooth audit process.
- Collaborates with operations to support client transparency and understanding of the rebate process from claim to CMS reporting.
- Collaborate with the Clinical Pharmacy Managers and Client Support Specialists to add Medicare expertise and ensure a streamlined client experience.
- Leads the enterprise Quality and Safety Strategy to demonstrate TRHC excellence in this space and deliver excellent business and clinical results for our clients.
- Collaborates with TRHC University to create and provide educational courses for TRHC employees involved in support of MAPD clients.
Qualifications and Requirements:
- Pharmacy degree required, advanced preferred.
- Advanced degree in public health, business management, or healthcare- related preferred.
- 10-years of pharmacy leadership in managed care or prescription plan management.
- 5-years of Medicare Advantage Prescription Drug Plan and/or Prescription Drug Plan (PDP) with administrative management experience in Medicare or Medicare health care compliance.
- In-depth knowledge of Federal programs and the managed care industry and proven experience with Medicare quality and compliance.
- Understanding and experience working in the PBM industry.
- Excellent organization and analytical skills.
- Ability to read, analyze and interpret governmental regulations and legal documents.
- Ability to effectively present information and respond to inquiries from employees, regulatory agencies, health plan clients and others, as necessary.
- Personable, professional, possessing integrity
- Dependable and flexible
- Demonstrated initiative in problem solving and following through on tasks
- Ability to create, motivate and inspire interdisciplinary teams focusing on resolution(s) of identified issues
- Ability to maintain confidentiality of client and organizational information
- Ability to work sensitively and effectively with individuals of diverse ethnic and cultural back grounds
- Travel – ability to travel to Eau Claire, WI Pharmastar offices, TRHC offices and Medicare client offices, as needed - 20% based on need
The Company is proud to be an equal opportunity employer. All qualified applicants will receive consideration without regard to ancestry or national origin, race or color, religion or creed, age, disability, AIDS/HIV, gender, marital or family status, pregnancy, childbirth or related medical conditions, genetic information, military service, protected caregiver obligations, sexual orientation, protected financial status or other classification protected by applicable law.
- Pay Type Salary