Value Based Care Clinical Pharmacist - Care Management

Site: Mass General Brigham Community Physicians, Inc.Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.Job Summary The Clinical Pharmacist optimizes health outcomes by providing the highest level of patient care for a high-risk patient population within our health system.

In this role, the Clinical Pharmacist applies subject matter expertise to manage the pharmacy component of high-risk patient care management. As a member of Care Management teams, this role focuses on comprehensive medication management reviews, therapeutic alternatives, medication adherence quality performance, and post-discharge medication reconciliation.The individual will provide primary care-focused pharmacotherapy services to evaluate and manage patients with complex chronic primary care conditions (e.g., CKD/ESRD, Type 2 diabetes, hyperlipidemia, hypertension, COPD/Asthma) through direct patient care, as appropriate.

Additionally, the Clinical Pharmacist may align clinical pharmacy workflows to support and manage quality in our ACO contracts, ensuring the health system achieves key performance benchmarks and success across various performance-based initiatives.Principal Duties and Responsibilities1. Care Management Collaboration & Patient Engagement• Collaborate with the Care Management programs team and health system network providers to deliver coordinated pharmacist support to a high-risk patient population, which will require direct patient involvement via phone calls, telehealth, or office visits.• Provide counseling to patients, utilizing motivational interviewing to promote behavior change and improve health literacy.• Assess compliance barriers and develop tailored, patient-centered plans to improve medication adherence in alignment with health system contract quality • Address affordability concerns, which may include identifying cost-effective drug therapy regimens, simplifying complex medication regimens, and leveraging prescription assistance programs.• Perform Comprehensive Medication Management reviews for enrolled Care Management programs patients• Perform transitions of care medication reconciliation during transitions of care.• Assist the Care Management programs team in identifying high-risk medication issues that impact hospital readmissions and may develop proactive pharmacy strategies to improve post-discharge outcomes and support health system utilization goals.2.

ACO Contract Quality & Performance Initiatives• May actively manage and support clinical quality metrics within our various ACO contracts, helping to ensure health system patient outcomes align with shared savings benchmarks, adherence measures, and risk-based contract goals.• May drive and manage performance-based initiatives designed to hit key performance indicators and quality benchmarks tied directly to organizational Care Management programs.• Monitors, analyzes, and addresses ACO quality performance trends by identifying care gaps, implementing targeted medication management interventions, and collaborating with interdisciplinary teams to improve clinical outcomes and quality measure performance• Document all patient encounters, update medication lists, and communicate seamlessly with providers and Care Management programs team members via Epic and other electronic patient records.• May take an active role in the development, implementation, and tracking of pharmacy-led quality improvement projects to maximize performance across value-based agreements.• Participate in local health system site activities, which may include team meetings a