Director, Market Access
MDWerks Inc.
Director, Pharmacy Part B and Specialty Drugs
Alignment Health
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $149,882 - $224,823 per year
Job Level
Lead
About the role
- Overseeing and optimizing Medicare Advantage Part B drug utilization and specialty drug initiatives
- Lead specialty drug program design, execution, and monitoring across Part B and Part D lines within the Medicare Advantage business
- Serve as the subject matter expert on specialty drug trends, pipeline, and management strategies
- Develop and implement utilization management and programs to optimize cost and member outcomes
- Lead clinical policy development and pipeline monitoring for emerging high-cost therapies
- Oversee specialty pharmacy programs, contracts, and vendor performance
- Partner with finance and actuarial teams to forecast drug trends and manage Part B and Part D pharmacy P&L
- Track and improve performance metrics including drug spend , rebate performance, utilization trends, and Star quality measures
- Drive performance improvement initiatives to reduce unnecessary variation and ensure compliance with CMS requirements
- Lead the review and analysis of medical benefit drug claims, focusing on cost drivers, outliers, and opportunities for clinical intervention
- Collaborate with medical directors, care management teams, and providers to ensure evidence-based prescribing, site-of-care optimization, and effective care coordination
- Provide clinical guidance on prior authorization, step therapy, and medical necessity criteria for Part B drugs and specialty drugs
- Support formulary management by partnering with Pharmacy team , PBM /vendor , and Pharmacy & Therapeutics (P&T) Committee
- Ensure all programs are fully compliant with CMS regulations, NCQA standards, and internal policy requirements
- Maintain readiness for CMS audits and other regulatory reviews
- Build strong relationships with providers, infusion centers, and specialty pharmacies to support appropriate utilization and access
- Collaborate with contracting team to negotiate cost-effective agreements with vendors and providers
- Oversees assigned staff; recruiting, selecting, orienting, training, assigning workload, planning, monitoring, appraising, coaching, counseling, and performance management
Requirements
- 7–10+ years of leadership experience in managed care pharmacy, with direct experience in Medicare Advantage Part B and specialty drug management
- PharmD or advanced degree in pharmacy required
- Preferred: MBA, MPH, or health policy degree preferred
- Demonstrated expertise in specialty drug utilization management, formulary strategy, and regulatory compliance
- Strong understanding of CMS regulations governing both Part B and Part D
- Strong financial acumen with direct experience managing pharmacy budgets and performance outcomes
- Proven leadership, communication, and cross-functional collaboration skills
- Active pharmacist license
- Supervisory experience: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; coaching, counseling, and performance management
