Candidate must live in one of the following states: AZ, D.C., DE, FL, GA, IN, IA, KS, MD, MI, NC, PA, TX, VA, WV

Summary/Position Objectives:

This position is responsible for providing clinical guidance, reporting, program recommendations, and benefit strategies for the pharmacy program for Maryland Physicians Care (MPC) in support of Maryland Care Management, Inc. (MCMI’s) strategic vision. Identifies, leads, and measures the impact of pharmacy program opportunities that impact client cost, utilization, and quality metrics. Synthesizes client utilization data, benefit designs, and pharmacy clinical programs and provides client-specific recommendations to improve pharmacy program performance.

About Maryland Care Management, Inc. (MCMI):

Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care’s (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD’s largest Medicaid-managed care organizations.

Why join us?

MCMI recognizes the importance of flexibility and offers multiple work arrangements. Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans.

Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed. We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members’ lives.

What You’ll Do:

• Assist with the development, enhancement, and maintenance of operational functions, policy and clinical support, and member and provider education.
• Develop, implement, and monitor project plan requirements and timelines, ensuring all necessary support, tools, and technology are available.
• Meet with appropriate personnel to identify project goals, objectives, critical success factors, and success measures.
• Provide creative thinking and leadership in accomplishing goals of quality improvement and cost-effective prescription drug programs.
• Collect, analyze, interpret, and forecast health care cost information based on current prescribing patterns based on medical utilization reports.
• Assist in the development of educational materials and correspondences with members and providers to inform them about medication coverage choices, comparative effectiveness, and coverage determinations.
• Assist in the resolution of disputes, grievances, and complaints involving pharmacy program issues.
• Assist pharmacy contract administration with the development and implementation of key contracts and ensure that relevant performance standards are met by vendors.
• Provide clinical context for coverage recommendations for medications subject to prior authorization, appeals, retrospective claim reviews, and audits based on applicable medication coverage policies, member benefit contracts, and provider contracts.
• Participate in external accreditation initiatives, relevant boards, task forces, committees, meetings, and other activities.

Knowledge and Skills:

• Strong knowledge and understanding of the pharmacy benefit management industry, benefit design, pharmacy products, and services.
• Understanding of managed care pharmacy including drug utilization management, quality programs, and formulary management.
• Ability to interpret complex clinical information, claims data, and regulatory requirements to deliver practical business solutions.
• Experience with Microsoft Office Suite, with proven expertise in Microsoft Excel.

Education and Work Experience:

• Doctor of Pharmacy degree (PharmD).
• Current Maryland State Pharmacist License.
• 2+ years of clinical pharmacy experience.
• 2+ years recent contracting, quality improvement, and management experience in a managed care, insurance, PBM, or equivalent healthcare environment.

EEOC Statement:

Following applicable federal, state, and local laws, MCMI prohibits discrimination in employment based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, or any other characteristic protected by law. This commitment extends to all aspects of employment, including hiring, promotion, compensation, benefits, training, social and recreational programs, and all other conditions and privileges of employment. 

As a healthcare organization, we recognize the vital importance of inclusivity in delivering quality care to our patients. We strive to foster an environment where individuals of all backgrounds feel respected, valued, and supported. We aim to better comprehend the unique needs of our patients and provide healthcare services that are culturally competent and sensitive. 

We encourage candidates from all backgrounds to apply and join us in our mission to provide compassionate and inclusive healthcare. We believe that a diverse workforce enriches our organization and allows us to better understand, connect with, and serve our diverse patient population.