Quality Interventions Pharmacist

• Drive performance on pharmacy-related quality measures, including medication adherence, statin therapy, polypharmacy, and other HEDIS, CMS Star, and QARR measures assigned to the pharmacy team.
• Take initiative to analyze measure performance and gap lists, identify improvement opportunities, and propose and implement new outreach strategies, workflows, and interventions to improve quality measure performance.
• Conduct high-volume telephonic outreach to providers, members, and pharmacies to close gaps in care, resolve adherence barriers (e.g., refill timing, 90-day supply conversion, mail order, cost), and coordinate therapy changes.
• Educate providers and office staff on clinical guidelines, measure specifications, appropriate documentation and coding, and lab ordering practices that support gap closure; influence prescribing and care decisions and respectfully push back when clinically warranted.
• Perform root cause analysis for coding, documentation, and data inaccuracies; create provider-level work plans to measure office progress as needed.
• Conduct field visits to provider offices and/or pharmacies as needed to build relationships, deliver education, and support gap closure.
• Collaborate with providers, pharmacies (including specialty pharmacies), and members to update medication regimens, resolve discrepancies, and ensure optimal therapy outcomes.
• Assist members in improving medication adherence through patient education, counseling, and personalized adherence plans.
• Collaborate across the Quality team and with Provider Network, Clinical Services, Risk Adjustment, BI, and IT to coordinate outreach and maximize gap closure.
• Support the training, onboarding, and ongoing mentorship of Quality Intervention Coordinators and other team members; serve as the go-to pharmacy resource for clinical and measure-related questions.
• Serve as subject matter expert on pharmacy quality measures and clinical guidelines for the Quality team.
• Develop member and provider educational materials and training content related to HEDIS, Medicare Stars, QARR, medication management, adherence strategies, and drug interactions.
• Support supplemental data and medical record retrieval activities that contribute to accurate measure reporting, as needed.
• Stay current on HEDIS and CMS Star measure specification changes; State, health plan, NCQA, and CMS regulatory updates; and pharmacy and industry trends, and share relevant updates with the team.
• Adapt to shifting priorities and take on new projects and assignments as business and health plan needs arise.

• Pharmacy expertise in medication therapy management, medication adherence, chronic disease management (e.g., diabetes, hypertension, hyperlipidemia), and drug interactions
• Knowledge of HEDIS, CMS Star Ratings, and/or NYS QARR measures, particularly Part D and pharmacy-related measures, is a strong plus
• Strong verbal and written communication skills, with the ability to influence providers, persuade, and respectfully push back when clinically appropriate
• Comfortable with high-volume telephonic outreach and building rapport with provider offices, members, and pharmacies
• Strong analytical and problem-solving abilities; able to work with large, complex data sets (e.g., gap lists, claims, pharmacy fill data, and performance reports) and translate findings into prioritized outreach and actionable strategies
• Proficiency in Microsoft Excel and Office; experience with quality or outreach platforms or EMR systems is a plus
• Ability to work independently, prioritize tasks, and manage multiple responsibilities
• Willingness to perform field work, including visits to provider offices and pharmacies, with access to reliable transportation

• Passionate about quality improvement and patient care, and takes pride in their work
• Self-motivated and takes initiative, identifying problems and proposing solutions without waiting to be asked
• Constantly thinking about new, innovative ideas and strategies to improve measure performance
• Quick learner who is thorough and detail-oriented in their processes
• Proactively stays current on quality measures, pharmacy trends, and industry developments
• Collaborative team player who is willing to jump into different priorities as they arise and supports the growth of others through training and mentorship

• Doctor of Pharmacy (PharmD) degree from an accredited institution is required
• Certification in CRC (Certified Risk Adjustment Coder) is required and must be maintained in active status. If not obtained prior to hire, the certification must be completed within the first 120 days of employment.
• Completion of a pharmacy residency is preferred

• Minimum of three years of experience in medication management
• Experience in managed care (health plan, IPA/MSO, PBM, or ACO) preferred
• Experience with HEDIS, CMS Star Ratings, and/or QARR quality measures, including medical record review and/or reporting processes, is a plus
• Experience with medication adherence programs or quality improvement initiatives preferred
• Experience with provider, member, and/or staff education
• Bilingual skills are a plus

Department: Quality
This is a non-management position
This is a full time position