Director, Clinical Pharmacy and Utilization Management

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1 Director, Clinical Pharmacy and Utilization Management Tufts Health Plan Watertown, MA January 2014

2 Summary Tufts Health Plan (Tufts) seeks a Director of Clinical Pharmacy and Utilization Management to strategically lead a very important part of its organization. The Opportunity Tufts Health Plan is a health plan known for its progressiveness and for its high quality work environment, having been repeatedly named as one of the Great Places to Work by the Boston Business Journal. See This high visibility position is an opportunity to provide strategic leadership and farsighted vision in designing and managing the formularies and programs for our pharmacy benefit, as well as utilize operational skill in improving efficiencies and synergies with other departments. The Organization Founded in 1979 as a not-for-profit health maintenance organization, Tufts Health Plan is one of the nation s most highly rated health plans. The company is distinguished for providing an outstanding member experience and access to quality care. Tufts Health Plan offers a broad array of health care coverage options to individuals and employer groups. Through diverse product offerings, the plan covers members regionally and across the country. Its tagline No one does more to keep you healthy expresses a core commitment to offering plan members innovative tools and resources that engage them in enhancing their health and well-being, and managing health care costs. With over one million members, Tufts Health Plan is a significant player in its market and continues to strengthen its position. Tufts Health Plan features a fast-paced work environment, a high percentage of long term employees and an open and welcoming culture. Tufts Health Plan is a leader in advancing public policy discussions on several issues: prevention and wellness, affordability, and removing obstacles to accessibility. From traditional HMO and PPO plans to national, tiered and limited network plans, Tufts Health Plan provides quality health care coverage across the spectrum of an individual s needs. A historical perspective: In November 2011, Tufts Health Plan acquired Network Health, a managed Medicaid plan, making it one of only a few insurers in Massachusetts to offer commercial, Medicare and Medicaid coverage. In mid-2011, Tufts Health Plan developed two new product offerings aimed at providing quality, affordable health care coverage: o o The Your Choice Tiered Network Option plan Steward Community Choice, a limited-network, community-based plan developed in conjunction with Steward Health Care System In 2009, Tufts Health Plan entered the Rhode Island health insurance market with a suite of HMO, PPO, and deductible plans. Tufts Health Plan Medicare Preferred, a Medicare Advantage plan, offers health care coverage options for Medicare beneficiaries and retirees. Since 1998, Tufts Health Plan has had the highest enrollment in the state in Medicare Advantage plans, totaling more than 100,000 members. In December 2004, Tufts Health Plan joined forces with CIGNA to offer CareLink, a national, open-access health plan that gives multi-state employers the advantage of working with 2

3 experienced health care leaders committed to helping them achieve affordable coverage for all employees regardless of where they live. Quality Performance In 2012, Tufts Health Plan was the top-ranked commercial Preferred Provider Organization (PPO) plan in the country and fourth highest ranked overall by the National Committee of Quality Assurance (NCQA). Its commercial Health Maintenance Organization/Point-of-Service Option (HMO/POS) combined product was ranked No. 2 in the nation. This is the ninth consecutive year that Tufts Health Plan has been ranked among the top health plans by NCQA (NCQA s Health Insurance Plan Rankings Private). Since 1999, these products have achieved the highest possible accreditation status from the NCQA for consumer protection, quality improvement and clinical effectiveness. In its quality ratings analysis, the Center for Medicare and Medicaid Services (CMS), reviewed 45 unique quality metrics to award Tufts Medicare Preferred HMO plans 4.5 out of 5 stars for This ranking puts the plan among the top five percent of Medicare Advantage plans nationwide. Corporate Citizenship Founded in 2008, the Tufts Health Plan Foundation s mission is to promote healthy lifestyles and deliver quality health care in our communities. The foundation s focus is Healthy Aging improving the lives of adults ages 60 and older. The foundation funds more than $2 million annually in grants to nonprofit organizations throughout Massachusetts and Rhode Island to elevate the well-being of older adults and help them live healthier lives. For seven consecutive years, the U.S. Environmental Protection Agency has awarded Tufts Health Plan the ENERGY STAR label for superior energy performance at its Watertown headquarters. Tufts Health Plan was the first health care organization in New England to earn the ENERGY STAR label. Tufts Health Plan also has earned the Best Workplace for Commuters designation from the EPA. In June 2013, Tufts Health Plan earned a Best Employers for Workers Over 50 award from AARP and the Society for Human Resources Management. In November 2012, Tufts Health Plan earned a 10th place ranking among participating large Massachusetts employers in The Boston Globe Top Places To Work and was the highest ranked health insurance organization in the survey. Tufts Health Plan received the Leaders in Diversity award from the Boston Business Journal in October 2011 for building a diverse workforce that is reflective of the communities it serves. Fast paced, professional office environment handling multiple demands. Must be able to exercise appropriate judgment as necessary. Must possess the ability to react quickly and calmly under pressure. Requires the mental ability to deal with complex situations and individuals in distress. The Position The Director of Clinical Pharmacy and Utilization will lead the development and implementation of formulary and pharmacy programs for all Tufts Health Plan products and plans, including Commercial and Medicare Advantage. He or she will direct the contracting, budgeting, and management of home infusion and specialty pharmacy networks, and oversee pharmacy utilization management (including coverage determinations, exception reviews, and oversight of all operational activities) consistent with 3

4 Federal and State regulatory and accreditation standards. This Director will work with the Director of Analysis & Reporting to develop budget assumptions, select metrics for reporting, and interpret/analyze performance. S/he will interpret and comply with regulatory and accreditation requirements for formulary and pharmacy programs. The position will establish priorities and identify new initiatives that are consistent with corporate strategy and business plans. This position: Directs the development and maintenance of the formulary and pharmacy programs, including the Commercial, Medicare Preferred, and Generic Focused formularies. Directs the annual review of all formularies and pharmacy programs, including a competitive analysis, cost-benefit review of programs, and trend review by therapeutic class. Works with Pharmacy Benefit Manager (PBM) to monitor pharmacy spend and performance in order to identify opportunities for improved management. Directs pharmacy utilization management, including coverage determinations, exception reviews, and operational oversight, consistent with Federal and State regulatory and accreditation standards. Directs the contracting, budgeting, and management of Home Infusion and Specialty Pharmacy networks. Monitors industry trends and evolving reimbursement methodologies to identify potential opportunities. Works with the Director of Analysis & Reporting to develop budget assumptions, select metrics for reporting, and interpret/analyze performance. Develop quarterly dashboard reports that identify cost drivers, management opportunities, and status of initiatives. Identifies initiatives for medical cost reduction, administrative cost reduction and/or market competitiveness. Directs the business evaluation implementation through collaboration and communication with other departments. Represents Pharmacy Services at inter-departmental meetings and on projects. Identifies implications for Pharmacy Services department and facilitate/coordinate follow-up with others in the department. Disseminates information and provide periodic updates as needed. The Candidate The right candidate for this position will be a true leader with a ten year track record of success in management, program development and implementation, contract management and budget development. S/he must have a clinical background (ideally a PharmD, RPh or RN), and ideally Masters level education. Experience in contracting/provider relations, with a fundamental knowledge of health care delivery system, provider reimbursement methodologies, and health policy issues is required. S/he must have extensive knowledge of medical services and professions, health-related issues, and health care regulations. The right candidate should: Have keen analytic and quantitative skills necessary to interpret pharmacy utilization and cost trends, contracts, and payment methodologies. Ability to analyze/interpret performance metrics, regulatory requirements, and statutory/legal language. Demonstrate the ability to critically assess new programs and services, and their impact on formulary management and operations. Subsequently, be able to initiate, formulate and direct the implementation of new policies and programs. Possess the interpersonal and political skills to direct a department charged with making contractual and operational decisions across multiple products and services. Show considerable organizational and management ability, which is necessary to simultaneously conduct a diversity of complex projects in a complex organization. 4

5 Convincingly demonstrate strong leadership skills, with the able to guide and inspire others. Knowledge of health plan and pharmacy benefit manager (PBM) operations, with ability to broker compromise and/or innovative solutions to performance challenges and/or new requirements. Be a strong negotiator. Personal characteristics include: The ability to consistently build strong working relationships with colleagues A practical and pragmatic business sense, leading to strong problem-solving skills The ability to think and plan strategically Politically astute, flexible, and adaptable, anchored by common sense and good judgment Possess exceptional staff management and mentoring skills Comfort with ambiguity and calculated risks A goal-directed, bottom-line results orientation The tools to thrive in a highly complex organizational structure Projecting a strong, credible personal presence that will engender confidence among internal staff and providers Being action oriented, with the ability to make decisions High energy, with the ability to thrive in a fast-paced environment Initiative Exceptional oral and written communication skills, including public speaking Commitment to high standards and continually striving for improvement Being both a collaborative team player and an effective team leader Thriving in a fast-paced environment and sometimes in pressured situations. Critical Success Factors The Director will: Build strong and sustainable relationships and gain the personal credibility required to interact and influence across departments Execute on pharmacy-specific objectives in the 2014 corporate business plan Nurture the ongoing and successful staff harmony and morale that has been a hallmark of the department Inspire and motivate the staff to implement the changes necessary to operate efficiently and successfully in the new healthcare environment. Compensation A compensation package will be constructed commensurate with the background and experience of the selected candidate. Most significant is the opportunity to join a dynamic company in a critically important role. 5

6 For More Information We welcome all referrals. Interested parties please send resume and cover letter to For additional questions please contact Jackie Rosenthal or Jeff Zegas at All contact with our office will remain confidential. Equal Employment Opportunity Tufts Health Plan is committed to developing an atmosphere that respects and values each employee's individuality. It is the policy of Tufts Health Plan to: Recruit, hire, train and promote persons in all job titles, without regard to race, color, religion, sex, national origin, age, sexual orientation, gender identity, disability, or veteran status; Base decisions on employment to further the principle of equal employment opportunity; Ensure that promotion decisions are in accord with principles of equal employment opportunity by imposing only valid requirements for promotional opportunities; Ensure that all personnel actions such as compensation, benefits, transfers, companysponsored training, education, tuition assistance, and social and recreation programs will be administered without regard to race, color, religion, sex, national origin, age, sexual orientation, gender identity, disability, or veteran status. 6

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