Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care.
G.E.H.A has one mission: To empower federal workers to be healthy and well.
The Utilization Management and Oversight Pharmacist will assist with corporate strategy to achieve better healthcare value and lower cost for our members, while ensuring quality pharmaceutical care for our members, in an effort to make our insurance product more competitive and support growth.
The Utilization Management and Oversight Pharmacist widely supports the operation of the pharmacy benefit and its functional teams. The position will be responsible for the following:
• Insuring proper medication utilization among our membership
• Developing and maintaining customized prior authorization criteria
• Developing and maintaining custom benefit exclusions
• Completing enterprise-wide drug information requests
• Preparing pharmacy recommendations for the pharmacy leadership
• Proposing and implementing pharmacy benefit design changes
• Increasing member outcomes by collaborating with other departments within the enterprise
• Supporting utilization review strategies and risk management related to the utilization of pharmaceuticals
• Collaborating with staff responsible for day-to-day activities of the Pharmacy Department
• Coordinating with other departments within the organization (ie: Care Management, SIU, Product, Marketing) to support strategic and operational objectives of the Pharmacy Department.
SKILLS
SKILLS
Clinical Pharmacist; Utilization Management and Oversight
Duties and Responsibilities
- Responsible for day-to-day management of clinical pharmacy needs within the department including controlled substance monitoring, high risk member monitoring, high dollar claim monitoring and customized prior authorization criteria and exclusion management
- Collaborates with plan level associates (including Pharmacy Vice President and Managers, Care Management, Medical Directors, Quality Management and others as necessary) to identify members requiring clinical pharmacy intervention(s)
- Independently completes accurate and comprehensive medication reviews and performs the corresponding member, care management, and other outreach as necessary
- Researches and synthesizes detailed clinical data related to pharmaceuticals to identify opportunities for improving quality or overall cost
- Serves as pharmacy SME on projects and clinical care activities; supports internal business partners such as Product Development, Care and Case Managers, Special Investigations, and Medical Operations
- Leads, manages and/or supports medical cost management, utilization management and medication management initiatives, projects and related activities
- Assists in pharmacy medication exception reviews coming in from multiple sources including OPM, PBM, GEHA Executive Leadership, GEHA Appeals Department, etc.
- Assists member-facing pharmacy staff by providing medication therapy evaluations, recommendations and next steps for members and providers
- Works in partnership with the Vice President and Clinical Manager of Pharmacy to plan, implement and maintain clinical programs and services
- Serves as clinical pharmacy resource and drug information specialist to medical, pharmacy, nursing and SIU staff
- Reviews medical policy drafts and provides recommendations for change to medical policy staff
- Assists member-facing pharmacy staff in assembling responses for prescriber/member appeals, grievances, disputes, inquiries and reconsiderations within established time periods
- Supports clinical quality and corporate HEDIS measures by providing pharmacy perspective and developing strategies to achieve goals
- Serves on internal committees and/or workgroups and completes special projects as assigned
Job Qualifications
Education
- Doctor of Pharmacy (PharmD) degree from an ACPE-accredited School of Pharmacy
- Postgraduate training/residency required
Experience
- Candidate must be licensed, or eligible for licensure, within the state of Missouri
- Candidate must have 5 years of experience, or completion of a PGY-1/PGY-2 residency with a managed care and/or drug information focus preferred
- Experience should include managed care
- Minimum three (3) years of managed care experience that has involved interaction with patients, providers and other healthcare professionals
- Knowledge of managed care pharmacy principles including medical exception reviews, formulary management, and utilization review required
- Candidate should possess an extensive understanding of evidence-based pharmacy practice, including disease specific therapies along with knowledge and ability to search medical literature for supporting clinical references
Skills/Certifications
- Must contribute to the One Team value of GEHA, be organized and have the ability to handle multiple projects
- Exemplary interpersonal, communication and organizational skills
- Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles, and accountability
- Proficient in Microsoft Office (Outlook, Word, Excel, Vizio and PowerPoint)
- Solid understanding of government scope (FEHB, OPM, FDA, ACA, USPSTF) required
- Competency in compendia navigation and research
Work-at-home requirements
- Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
- A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
- Latency (ping) response time lower than 80 ms
- Hotspots, satellite and wireless internet service is NOT allowed for this role.
- A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
How we value you
- Competitive pay/salary ranges
- Incentive plan
- Health/Vision/Dental benefits effective day one
- 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
- Robust employee well-being program
- Paid Time Off
- Personal Community Enrichment Time
- Company-provided Basic Life and AD&D
- Company-provided Short-Term & Long-Term Disability
- Tuition Assistance Program
While this is a remote opportunity, at this time G.E.H.A does not hire employees from U.S. territories or the following states: Alaska, Hawaii, California, Washington, Oregon, Colorado, Wyoming, Montana, New York, Connecticut, Vermont, Pennsylvania, Maine.
Please note that the salary information is a general guideline only. G.E.H.A considers factors such as (but not limited to) scope and responsibilities of the position, candidate’s work experience, education/training, key skills, internal peer equity, as well as, market and business considerations when extending an offer.
The hiring range for this position is $118,092 - $149,394 USD. At G.E.H.A, the current maximum salary for this role is $166,468 USD. While initial compensation may vary based on experience and qualifications, there is a path to work toward this top rate through performance and continued growth within the organization.
G.E.H.A is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. G.E.H.A will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. We are committed to creating an inclusive environment for all employees.
G.E.H.A is headquartered in Lee's Summit, Missouri, in the Kansas City area. We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.