Director - Pharmacy and Managed Care Services

Overview

Inspire health. Serve with compassion. Be the difference.

The Dir-Pharmacy Benefits & Managed Care Services is responsible for the strategic oversight, development, and management of all pharmacy benefit programs within the health plan and integrated health network. This role ensures that pharmacy services are clinically appropriate, cost-effective, and aligned with the organization’s overall care and financial strategies. The Director serves as the primary liaison among internal stakeholders, pharmacy benefit managers (PBMs), providers, and regulatory agencies to ensure optimal performance and compliance of the pharmacy program.

• All team members are expected to be knowledgeable and compliant with Prisma Health's purpose:
  Inspire health. Serve with compassion. Be the difference
• Provide strategic leadership and program oversight for pharmacy benefits program, focusing on quality, affordability, and member outcomes, serving as the subject matter expert for pharmacy benefits for the organization.
• Oversee PBM performance, including contract management, rebate administration, formulary development, and clinical program execution. Ensure accurate implementation of benefit designs across systems and platforms.
• Collaborate with actuarial, medical management, and finance teams to forecast pharmacy trends and budget impacts. Monitor and analyze pharmacy utilization data to identify cost drivers, trends, and opportunities for savings.
• Develop and maintain pharmacy policies and procedures in alignment with regulatory and accreditation standards (CMS, URAC, NCQA, etc.). Ensure all pharmacy programs comply with state and federal regulations, including Medicaid, Medicare Part D, and ACA requirements.
• Remain current on industry trends, drug pipeline developments, and legislative changes impacting pharmacy benefits. Evaluate new pharmacy technologies, vendors, and clinical programs for potential integration. Partner with appropriate stakeholders to align pharmacy strategy with broader health plan goals.
• Communicate pharmacy program performance, trends, and initiatives to executive leadership and committees.
• Performs other duties as assigned.

• Job has direct and/or indirect supervision of team members that may include final budget authority, hire/termination authority, performance appraisal responsibility and disciplinary authority. Job will be considered a member of management staff at Prisma Health or affiliate and will have direct reports.

• Education - Bachelors degree in Pharmacy from an ACPE accredited program.
• Experience - Five (5) years of related experience.

• In lieu of pharmacist licensure and degree in pharmacy, will consider MBA, MHA or MPH degree and 8 years of relevant experience.

• Pharmacist license from state in which work is performed.

• Deep knowledge of formulary management, rebate contracting, specialty pharmacy, and utilization management.
• Strong analytical skills with the ability to interpret complex data and develop actionable insights.
• Proven leadership and communication abilities, with the capacity to influence executive stakeholders.
• Proficiency in pharmacy benefit software, claims systems, and analytics platforms. Knowledge in reimbursement models and health plan organizations

Day (United States of America)

Corporate

7001 Corporate

Pharmacy System Support