Case Management Clinical Pharmacist

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
May 20, 2025
Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more. The Case Management (CM) Clinical Pharmacist will be responsible for supporting the Medicare lines of business with optimizing clinical care outcomes by developing and implementing quality programs across various Medicare teams within the organization. As a CM Medicare Clinical Pharmacist in this role, you will identify areas of opportunity and work in collaboration with other stakeholders to perform interventions that maximize member care. This role will also work to improve Centers for Medicare & Medicaid Services (CMS) required clinical programs and develop, implement, and document best practices related to member care and experience. This is a member-facing role. Duties and Responsibilities: Perform regular and yearly claim and data analysis to identify and conduct interventions to optimize quality of care Monitor all types of member and provider data to identify savings opportunities and other gaps in care related to adherence, complex medical conditions found commonly in the Medicare population, STAR measures and latest clinical guidelines Counsel members and providers on gaps in care, preferred product strategies, medication adherence, clinical guidelines and more Perform Comprehensive Medication Reviews (CMR) in collaboration with our MTM vendor and for our other medically complex members not eligible for MTM Collaborate with numerous teams including, but not limited to, Clinical Pharmacy Operations, Quality, STARs, and Fraud Waste and Abuse on clinical opportunities as well as CMS required reporting Support Medicare-related auditing and all Medicare required reporting functions related to STARs, MTM, and other clinical programs Aid in the education of members and providers on the impact of existing and new Medicare regulations regarding prescribing practices and member experience Provide clinical support in the coordination of care for our members Download and review monthly CMS Patient Safety Reports Take the lead on identifying opportunities and interventions required, involving other impacted teams when applicable Perform member and provider interventions to address CMS concerns Compile required documentation on interventions and other activities Build files and other response materials in compliance with CMS requirements Conduct direct member engagement and pharmacist consult support for other clinicians and clinical teams, such as providing formulary alternatives when requested by members or providers Provide member education and aid in member navigation through various aspects of their Medicare benefits, including specific plan details as well as general Medicare rules surrounding pharmacy and medical benefits Qualifications: Pharm D Valid, Unrestricted Pharmacist License Required Required Experience: Minimum 2 years of experience in managed care/case management Minimum 3 years of Medicare experience Minimum 1 year Medicare Medication Therapy Management (MTM) Program and CMR experience Preferred/Desired: STAR Measure reporting Skills/Abilities/Competencies: Demonstrate MGBHP core brand principles of always listening, challenging conventions, and providing value. Bring fresh ideas forward by listening to and working with employees and the people we serve. Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner. Strong, demonstrated track record of the ability to execute on time, on budget, and on scope. Strong aptitude for technology-based solutions. Ability to inject energy, when and where it's needed. Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation and communication skills. Strong verbal, active listening, and written communication skills required. Excellent interpersonal skills, including the ability to influence others at all levels of an organization. Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Unquestionable integrity. Excellent organizational and analytical skills. Excellent judgment and decision-making abilities. Strong influencing skills and perseverance Ability to develop and motivate employees to meet departmental and organizational objectives. Ability to manage multiple projects, meet deadlines and nimbly adjust to changes in company policies, procedures and priorities Working Conditions: Normal office working conditions. Remote, Hybrid or onsite Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.