CareSource is looking for a Manager, Medical Drug Strategy & Execution to lead the development of medical drug strategy and oversee specialty and physician administered drug operations. You will ensure compliance and drive initiatives that optimize cost and outcomes.
What You'll Do
- Coordinate the implementation and execution of medical drug strategy and manage the pre-determination process for specialty pharmacy.
- Drive biosimilar adoption, utilization pathways, clear/white bagging policies, specialty pharmacy partnerships, and sourcing strategies.
- Optimize infusion and specialty drug administration settings for cost savings and improved outcomes.
- Lead execution of CMS/state drug requirements across systems and providers, including Part B Implementation.
- Lead QAI efforts for medical drug spend and utilization to support cost containment and drive medical forecasting.
- Coordinate and collaborate with Pharmacy, Medical, Network, Finance, and Operations to ensure unified execution.
- Assist in developing integrated service delivery to members and oversee data and processes to maintain industry standards.
- Assist the Director in developing processes to manage appropriate utilization and assure appropriate payment for specialty/medical drug services.
- Interact with providers and staff to manage benefits aligned with regulations, URAC and NCQA regulations, and CareSource policies.
- Oversee CQI activities and document departmental processes for internal and external use.
- Review and revise workflows to maximize efficiencies.
- Monitor productivity and utilization trends.
- Regularly report all specialty pharmacy/medical drug data and program performance.
- Ensure compliance with and reporting of all regulatory requirements.
- Analyze and formulate recommendations based on data.
- Maintain and update all departmental policies and procedures.
- Act as liaison with other departments to assist with research and intervention.
Team & Environment
You will report directly to the Director.
