The position will be responsible for the successful development and deployment of the Vaya Health Tailored Plan pharmacy benefit program working in collaboration with the Pharmacy Benefit Manager (PBM) vendor partner, other Vaya team members and the North Carolina Department of Health and Human Services (NCDHHS). This position will perform pre-work and work with the PBM prior to implementation to help drive key decisions to establish the benefit configuration for plan, utilization management and clinical program set up The position holder will assist with Vaya staff training on the new policies and procedures, establish and roll out a plan for PBM oversight as part of implementation and ongoing monitoring, and participate in the plan readiness review. Post-implementation responsibilities will include but are not limited to oversight and monitoring of PBM contractual terms and services including monitoring of PBM adherence to the NCDHHS preferred drug list, timely evaluation of encounter files, oversight of PBM compliance, evaluation of PBM pharmacy reports, coordination and evaluation of PBM support of any responses to governmental inquiries, and act as subject matter expert in evaluation of PBM developed presentations and proposals.
Manage PBM Relationship and Services
• Responsible for directing and providing operational and contractual oversight of the PBM to ensure full compliance with all Federal, State and local laws, regulations and NCDHHS pharmacy program policies.
• Oversee the contract between Vaya and the PBM to ensure the PBM performs within contractual terms and service levels.
• Collaborate with the PBM in implementing and monitoring Vaya strategic plans as it relates to the pharmacy program.
• Support the NCDHHS Readiness Review.
• Be Vaya’s primary point of contact with NCDHHS for all matters related to Vaya’s pharmacy benefit program.
• Work with the Vaya Clinical Pharmacist on PBM implementation and monitoring of all NCDHHS required clinical, utilization management, and fraud, waste & abuse programs.
• Coordinate from Vaya’s end in planning and coordination of implementation meetings.
• Evaluate accuracy of PBM provided data to be included in bids, reports and in response to inquiries, including provision of underwriting, actuary, sales, and marketing resources.
• Maintain a PBM Activity Log which shall include a summary of the inquiry, issues, and defects, as well as tracking of all action steps taken or required for resolution of such issues and a date for resolution of the Inquiry.
Pharmacy Program Development, Support and Operations:
• Develop and/or refine Vaya pharmacy related policies and procedures, particularly those linked to delegated PBM activities and Vaya integrated medical/pharmacy programs. Assist Vaya staff training on the new PBM related policies and procedures.
• In collaboration with the Vaya Chief Medical Officer, establish, coordinate, and participate on the Vaya PBM Oversight and Governance Committee.
• Schedule, coordinate and attend quarterly and annual business reviews of the pharmacy benefit program with the PBM and Vaya leadership which shall include those topics and issues designated by Vaya.
• Manage PBM’s support of Vaya in audits by Governmental Authorities, including but not limited to NCDHHS, HRSA or CMS, such support to include coordinating with Vaya to report to the auditing entity the commencement, conclusion and final results of all audits.
• Responsible for evaluating the presentation of information on forthcoming market events that may impact Vaya, including pipeline reports and anticipate new drugs coming to market and single source Brand Drugs moving to multi-source Generic Drugs.
• Works to evaluate the presentation of new PBM products and services to Vaya to support meeting Pharmacy Program objectives, including Vaya’s expansion plans.
• Stay up to date on current applicable legislation and evaluate PBM’s interpretation of legislative updates to Vaya regarding new and/or pending state or federal legislation, regulations or guidance, including but not limited to NCDHHS, HRSA or CMS, that will impact the Vaya Pharmacy Program.
• Serve as an educational resource on PBM matters for internal Vaya team members and applicable external customers.
Remote work position but is required to reside in North Carolina. Registered pharmacist with a current, unrestricted pharmacist license from North Carolina Board of Pharmacy required. Managed care and PBM experience required. A minimum of three (3) working years of Medicaid PBM experience is preferred.
Internal Number: 100
About Vaya Health
Vaya Health manages publicly funded behavioral health and intellectual/ developmental disability services in western North Carolina. We believe whole-person care – with a focus on both mind and body – is essential to overall health.