Pharmacy Quality Specialist

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The Pharmacy Quality Specialist supports pharmacy quality initiatives focused on improving medication-related quality outcomes, including Medicare Star Ratings, HEDIS, and other organizational quality measures. Working collaboratively with pharmacists, pharmacy leadership, providers, members, pharmacies, and internal teams, the Specialist identifies and addresses medication-related care gaps through member and provider outreach, data review, intervention tracking, and care coordination. This role has a strong focus on medication adherence and pharmacy quality measures, supporting proactive identification of opportunities and timely interventions to improve member outcomes and organizational quality performance.

The Pharmacy Quality Specialist supports initiatives across multiple measures, including medication adherence, statin use, medication safety, and other pharmacy-related quality programs.

• Runs and reviews daily, weekly, and monthly reports to identify members with medication-related care gaps and opportunities associated with Medicare Stars, HEDIS, and other quality measures.
• Conducts telephonic outreach to members to identify barriers to medication adherence and support timely access to prescribed medications.
• Educates members regarding prescription refills, medication access, pharmacy options, benefit resources, and available assistance programs within the scope of the position.
• Conducts outreach to provider offices and pharmacies to support resolution of medication-related quality gaps and facilitate timely interventions.
• Supports pharmacy quality measures including Diabetes Medication Adherence, RAS Adherence, Statin Adherence, Statin Use in Persons with Diabetes (SUPD), Concurrent Use of Opioids and Benzodiazepines (COB), and Polypharmacy:
  Use of Multiple Anticholinergic Medications (Poly-ACH).
• Reviews pharmacy claims, medication histories, and other available data to identify adherence concerns, refill opportunities, potential medication discrepancies, and quality measure gaps.
• Identify members requiring pharmacist clinical review and appropriately escalates medication-related concerns or interventions requiring professional judgment.
• Tracks identified quality opportunities from initial identification through outreach, intervention, follow-up, and resolution.
• Performs ongoing follow-up with members, providers, and pharmacies to facilitate closure of identified care gaps.
• Documents member, provider, pharmacy outreach and intervention outcomes accurately and consistently within designated systems and tracking tools.
• Maintains logs, dashboards, reports, and other tracking mechanisms used to monitor quality measure performance, outreach effectiveness, and intervention outcomes.
• Supports targeted campaigns and quality improvement initiatives designed to improve medication adherence and pharmacy quality performance.
• Collaborates with pharmacists and pharmacy leadership to identify trends, barriers, and opportunities for improvement based on outreach and quality measure data.
• Serves as a liaison between members, providers, pharmacies, pharmacists, and internal departments to facilitate communication and resolution of medication-related quality opportunities.
• Assists members in navigating medication access barriers, including refill coordination, pharmacy-related issues, and benefit questions, escalating complex issues as appropriate.
• Supports provider-facing initiatives, including preparation of outreach materials, identification of actionable opportunities, and follow-up on pharmacist or provider recommendations.
• Participates in pharmacy quality meetings, team huddles, and other interdisciplinary meetings as appropriate.
• Assists with special projects and process improvement initiatives related to pharmacy quality, member experience, and medication-related outcomes.
• Maintain knowledge of applicable quality measures, workflows, policies, procedures, and regulatory requirements.
• Performs other duties as assigned to support pharmacy quality initiatives and organizational goals.

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

• Education:
  
  High School Diploma or equivalent
• Licensure/certification:
  Required to have an active Maine Pharmacy Technician…