Introduction
To heal, to teach, to discover and to advance the health of the communities we serve.
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Overview
The Transitional Care Clinical Pharmacy Manager is a core clinical team member within Montefiore’s multidisciplinary Transitional Care Excellence department. This role sits at the intersection of inpatient care, ambulatory management, and population health, with a focus on improving outcomes for high‑risk cardiovascular‑kidney‑metabolic populations.
Responsibilities
- Leads longitudinal pharmacotherapy management for a defined panel of high‑risk patients with cardiovascular‑kidney‑metabolic syndrome hospitalization, utilizing telemedicine, remote patient monitoring, and in‑person care models.
- Initiates, optimizes, and titrates guideline‑directed medical therapy (GDMT) under collaborative drug therapy management (CDTM) agreements, with a focus on heart failure, ASCVD, diabetes, obesity, and CKD.
- Identifies and acts on high‑impact clinical opportunities early in the post‑discharge period to prevent readmissions and disease progression.
- Solves complex medication‑related challenges including access, affordability, adherence, and health‑related social needs.
- Serves as a clinical bridge across inpatient, ambulatory, and post‑acute settings, ensuring seamless care transitions and accountability across the continuum.
- Partners with physicians, advanced practice providers, nurses, and navigators to design and execute high‑reliability care pathways.
- Acts as a key liaison to post‑acute partners including home care, skilled nursing facilities, and rehabilitation centers.
- Contributes to quality improvement initiatives aligned with CMS Star Ratings, HEDIS measures, and value‑based care contracts.
- Participates in program development, innovation (e.g., telehealth optimization, AI‑enabled outreach, RPM workflows), and scaling of disease‑specific care pathways.
- Engages in academic and scholarly activities including research, protocol development, and dissemination of outcomes.
Requirements
- Doctor of Pharmacy degree is required.
- Advanced training (e.g., completion of a PGY‑2 residency in cardiology, ambulatory care, or other relevant specialties) or completion of a PGY‑1 residency with current board certification and 3 years of relevant experience are required.
- Valid NYS Pharmacist license and registration with eligibility to be credentialed as an allied health professional.