It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Reporting to the Director of Pharmacy Services, the Quality Program Pharmacist is primarily responsible for supporting pharmacy services’ clinical quality improvement activities, NCQA accreditation management activities, and implementation of clinical and formulary programs. In addition, the Quality Program Pharmacist is accountable for clinical quality improvement initiatives which comply with contractual obligations, regulatory requirements and accreditation standards. Responsibilities will include supporting quality assurance activities related to consistent and accurate utilization management reviews, formulary implementation, and monitoring and assessing clinical program outcomes. This includes development of clinical and quality program designs and implementation.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

• Responsible for quality improvement activities and initiatives, including those that support requirements to meet NCQA standards and other state and federal regulations and contracts
• Leads pharmacy services activities related to NCQA to ensure accreditation requirements are met and maintained for ongoing reaccreditation
• Develops and implements clinical quality programs that address industry and regulatory health-related gaps in care
• Responsible for goal design, implementation, tracking, reporting and evaluating overall effectiveness of the initiatives
• Identifies innovative strategies to impact Plan’s quality goals and outcomes
• Collaborates with key internal stakeholders and Plan’s pharmacy benefit manager to identify areas of potential cost-saving and quality improvement initiatives
• Assesses clinical program outcomes using data-driven analyses and determines opportunities for improvement
• Work with clinical/quality, data analytics team and others as needed, to ensure that data needs are identified and incorporated into the process including performing data analysis as needed
• Serve as the quality liaison to the PBM and oversee quality programs administered by PBM
• Conducts quality assurance analyses of utilization management reviews to ensure consistency and appropriate decisions in accordance with Plan policies
• Responsible for implementing clinical policy updates and training of staff in the application of policy criteria to utilization management reviews
• Responsible for testing and validation of formulary configuration
• Supports formulary configuration activities as needed
• Participates on quality committees and/or lead cross-functional workgroups as necessary
• May provide guidance and direction to pharmacy services staff pertaining to responsibilities noted
• Other duties as assigned

Qualifications:

• Excellent written and oral communication skills
• Excellent interpersonal skills
• Strong organizational and time management skills, including ability to work independently and prioritize multiple projects and assignments
• Able to collaborate cross-functionally
• Ability to analyze, compile, format, and present findings, data, queries, and reports to a variety of stakeholders
• Demonstrates ability to provide guidance and oversight
• Demonstrated strength in analysis, identification of problems and issue resolution
• Excellent skills in teamwork and team approaches to goal setting and attainment
• Must be results oriented

Education & Experience:

• Minimum of professional Registered Pharmacist degree required. Graduate study in a business, public health, or health policy field will be favorably considered
• Unrestricted current and valid license to practice pharmacy in the state of Massachusetts and/or in any other relevant/applicable state
• Experience in a managed care setting, either from the provider, the payer, or the PBM side of the industry, is preferred
• Proficiency in standard computational office-suite applications, including word-processing and relational database manipulation is required

Competencies, Skills, and Attributes:

• Experience with regulatory and accreditation standards
• Organized with clear communication
• Comfortable working with data
• Experience with audits

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the
• Occasional travel (<5%) may be required
• Ability to work in a fast paced environment

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.

• WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.