Pharmacist, Utilization Management

Title: Pharmacist, Utilization Management
Reports to: Director, Pharmacy Benefits
Classification: Individual Contributor
Location: Boston, Hybrid
Job description revision number and date: V 3.0; 3.31.2025

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices nationally. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

SCO and One Care Summary:

The Senior Care Options (SCO) and One Care programs are health plan programs for dually eligible

(Medicare and Medicaid) individuals (“duals”) in Massachusetts. SCO serves eligible beneficiaries aged 65 , while One Care serves duals between ages 21-64. These programs are Fully Integrated Dual- Eligible Special Needs Plans (FIDE-SNP) that integrate Medicare and Medicaid benefits, along with additional supports for enrollees such as integrated care teams, care managers, social supports, etc.

Massachusetts’ Medicaid (MassHealth) agency recently conducted a procurement for health plans to offer products in these two programs, for a five-year term starting January 1, 2026. C3 submitted a bid and was selected in September 2024.

Job Summary:

The Pharmacist, Utilization Manager will support SCO and One Care members, and report to the Director of Pharmacy Benefits. The Pharmacist is responsible for day-to-day operations of the SCO and One Care plans. This role involves working with the Pharmacy Benefit Manager (PBM), oversight of

PBM delegated reports, oversight and management of the plan’s formularies for Medicare and Medicaid, performing utilization management, and clinical collaboration with different teams within the organization.

Responsibilities:

• Development and implementation of policies and procedures, standard operating procedures, and workflows related to pharmacy operations and compliance per NCQA requirements
• Oversight of delegation to PBM (including but not limited to reporting to HPMS, formulary review and testing, PDE reports, STARs and other clinical programs, CDAG)
• Develop and maintain updates to prior authorization notifications to approval and denial letter templates
• Review of medical (Medicare Part B) drug/cost and management
• Work to identify and communicate significant regulatory risks and recommendations for mitigation to leadership
• Development of formulary management strategies related to specific drug coverage, step therapy protocols, quantity limits, and prior authorization guidelines
• Assists with review of pharmacy grievances and complaints as needed
• Reviewing PBM databases to extract and analyze pharmacy utilization and cost data
• Serves as a clinical resource and drug information specialist to medical, pharmacy, and nursing staff as needed (i.e.. quality measures, transitions of care, medication reconciliation, )
• May serve on internal committees and/or workgroups and completes special projects as assigned
• Assists in the development and maintenance of quality improvement projects, quality metrics, and quality outcome measurements
• Coordination of the activities of the Plan’s Pharmacy and Therapeutics Committee including clinical and financial reviews of individual drugs, drug classes, formulary development, and development of clinical policies and related metrics
• May assist with marketing and pharmacy-related member and provider communication materials
• Produce and analyze pharmacy cost trends and support pharmacy benefit design in collaboration with finance and actuarial teams and the PBM partner
• Other duties as assigned

Required Skills:

• Experience with utilization management (Medicare part D, Medicare part B, appeals and grievances)
• Strong analytical and problem-solving skills
• Excellent communication and interpersonal abilities
• Managed care or PBM experience
• Must be self-motivated and capable of working independently with minimal supervision
• Must be flexible and able to constantly review and reset priorities
• Organized and can simultaneously execute through multiple projects and priorities

Desired Other Skills:

• Working knowledge of federal and state pharmacy laws, rules and regulations
• Knowledge of drug coding NDC, GPI, and GCN claims adjudication systems
• Familiarity with Federally Qualified Health Centers
• Familiarity with SCO/OneCare
• Familiarity with managed care audits, including CDAG, ODAG, and data validation
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred

Qualifications:

• Advanced degree (PharmD, MBA, MHA) preferred
• RPh in good standing in Massachusetts required
• Minimum of 3 years of experience in managed care

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **