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Healthfirst Operations Pharmacist - FWA in New York, New York

The Operations Pharmacist - Fraud Waste Abuse (FWA) is a dynamic role, responsible for day-to-day clinical and operational oversight of the pharmacy benefit for all plans. The Operations Pharmacist, under direction of the Director of Pharmacy Operations, will support new initiatives, address drug cost trends through formulary management, partner with the PBM, enhance clinical monitoring of PBM delegated activities, and maintain compliance with all Federal and State agencies. The Operations Pharmacist is responsible for reporting, business process review and data analysis relating to activities ensuring operational effectiveness. The role will own project goals by developing project plans, establishing deadlines, monitoring milestone completion, providing timely reporting of issues that impact progress and resolving conflicts. This includes documenting and prioritizing assignments. This position reports to the Director of Pharmacy Operations.

This position has a hybrid work location: remote - work from home and working at our New York office located at 100 Church Street, New York, NY.

Duties & Responsibilities:

  • Work with Pharmacy Operations Director to oversee clinical operations of the pharmacy benefit

  • Collaborate with the Pharmacy Finance Manager, Special Investigations Unit, and PBM to address drug cost trends for all plans

  • Develop a pharmacy-based process, in conjunction with SIU and PBM, for systematically identifying FWA opportunities that includes identification, tracking, reporting, financial impact, quality and program improvement for both pharmacy and medical benefit drugs

  • Support and coordinate the Restricted Recipient Program (RRP) by managing referrals, providing recommendations to the RRP Committee, collaborating with other departments, such as behavioral health and SIU, and serving as the main point of contact for the program

  • Manage cross-functional projects between Pharmacy and other HF business units

  • Review member, provider, and pharmacy reports, and provide feedback on trends, ideas for improved management, and innovation

  • Oversee and maintain compliance with all State and Federal agencies

  • Work with the Finance team to monitor PBM data and activities

  • Provide clinical pharmacy support for the including but not limited to: override requests, program design, program implementation, content creation, training material development, etc.

  • Additional duties as assigned

Minimum Qualifications:

  • Pharmacy degree from an accredited school of pharmacy

  • Registered Pharmacist in NY State with a license in good standing

  • Strong operational and clinical knowledge of pharmaceuticals and disease states in an effort to identify and recommend opportunities for trend management

  • Demonstrate critical thinking and problem-solving skills

  • Ability to lead large and small working meetings

  • Strong clinical writing, verbal, and presentation skills

  • PC Skills with Microsoft Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables)

  • Passion for learning/ teaching, promoting access to healthcare, and interest in growing skills in a dynamic environment with various opportunities

Preferred Qualifications:

  • PGY1 Managed Care Residency (optional)

  • Experience with the Restricted Recipient Program (RRP)

  • Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits

  • Experience with pharmacy benefit management oversight including maintaining policies and procedures related to formulary design and utilization management processes

  • Knowledge of regulations of the Centers for Medicare and Medicaid Services and the New York State Department of Health

License or Certification: Licensed pharmacist in good standing.

Regulatory or Compliance activities: Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.

Please note: Since we care so greatly about our employees' and members' wellbeing, Healthfirst is moving to a fully vaccinated in-office environment. You must be vaccinated to work in our offices, even if you are partially remote. If you are selected to interview for this role, we will explain our vaccination policy and ensure you are comfortable moving forward with further interviews based on your work location.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement (http://www.dol.gov/agencies/ofccp/posters)

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

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