Request Expert

Expert is a resourceful Director of Pharmacy Operations with 10+ years of experience in pharmacy benefit management (PBM), retail pharmacy, and health systems. He is licensed in Arkansas, Alabama, Arizona, Hawaii, Illinois, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Oklahoma, Oregon, Nebraska, Nevada, Tennessee, Texas, Virginia, and West Virginia.

Throughout his career, expert has been responsible for developing, implementing, maintaining, and optimizing formularies and utilization management criteria for standard and specialty medications for pharmacy and medical drug benefits. He has identified clinically appropriate initiatives that maximize the value of rebates, assist with the management of the P&T committee process, and identify pharmaceutical trends, innovative technologies, and medications in the pipeline that will lead to budget impacts. To achieve this, he monitors the medication pipeline and provides forecasting information on the effect. He also evaluates specialty medication performance to identify trends and opportunities for pharmacy cost and utilization improvements. In addition, Expert has experience supporting pharmacy-related fraud, waste, and abuse efforts. He's worked closely with the pharmacy team and other internal partners to maintain NCQA accreditation levels for clinical pharmacy activities, including HEDIS and Stars related to specialty medications.

His role involves developing, implementing, and monitoring pharmacy care management programs, analyzing data to identify and educate prescribers on practice trends, patterns, and opportunities for lower cost and improved quality as needed to improve client, member, and provider satisfaction and experience. To promote efficiency and effectiveness in clinical pharmacy operations and pricing, he operationalizes and maintains processes for formulary management and maintenance, including benefit configuration, formulary submission, and communication of formulary changes, including medical benefit configuration for specialty medications. Expert ensures appropriate compliance with CMS/Medicare, Medicaid, and Commercial/QHP regulatory agencies, including reporting requirements. He assists with pharmacy prior authorization processes and cases related to specialty medications and maintain policies, procedures, and workflow documentation, and works closely with the pharmacy and network teams to manage specialty medication pricing, contracting, and case agreements as needed. Furthermore, Expert interfaces with external partners, providers, clients, members, or other customers to improve overall stakeholder satisfaction with the pharmacy offering. He collaborates with cross-department/cross-divisional teams to achieve goals, communicate department barriers and successes within the organization, establish relationships with specialty pharmacies, and monitor their clinical, operational, and financial performance.

HIGHLIGHTS:
● Pharmacy Benefit Management (PBM): 10+ years of experience in Medicare PBM, with a deep understanding of clinical programs such as DUR, B vs D, Hospice, CDAG.
● Product Management: Managing end-to-end product lifecycle, from ideation to implementation, with a focus on delivering exceptional pharmacy experiences.
● Strategic Planning: Skilled in developing product roadmaps, defining business requirements, and conducting market landscape analysis to drive strategic decision-making.
● Cross-Functional Collaboration: Strong ability to collaborate effectively with diverse teams, including technology, marketing, innovation, legal, and finance, to achieve product goals.
● Analytical and Problem-Solving Skills: Excellent at prioritization, scoping, and execution, with a data-driven approach to problem-solving and decision-making.
● Entrepreneurial Mindset: Demonstrated ability to think creatively, present ideas with clarity, and embrace an entrepreneurial and mission-driven approach.

SKILLS:
● Clinical Skills: Drug Utilization Reviews, PBM, Pharmacy Claims, Quality Assurance & Control, Patient Care, Treatment Assessments, Clinical Decision Making, Auditing, Formulary Management
● Leadership Skills: Team Leadership and Development, Project Management, Mentoring and coaching, New Office Start-Ups, Process Implementation and improvement, ROIs Specialist, RFP Requirement Specialist, Strategic Planning, Inventory Management
● Technical Skills: MS Office - Word, Excel, Outlook, PowerPoint, Project, and SharePoint; Tableau, Google Apps, RxClaim, NICE Scheduling, JavaScript