Clinical Pharmacist

gainwellte • Information Technology • 2w ago

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Summary

Evaluates utilization management criteria and impact for operational needs, supports and maintains configuration needs, develops clinical recommendations for the client, research policy drivers, and coordinates with operations, claims, network, reporting, and other internal departments as needed.

Your role in our mission

Utilization Management: Providing a thorough review of the clinical and pricing data to support clinical strategies; involves detailed reporting analysis.
Retro DUR Initiatives: Regularly reviews and monitors prescription claims data and prescribing practices identified as outliers by internal and/or external analysis of pharmacy claims data to develop relevant Retrospective DUR initiatives. Present initiatives to the P&T or DUR Board including methods, interventions, communication, and outcomes.
Telephonic Consultations/Interventions: Contacts physicians and prescribers identified as needing consultation to provide coaching on prescribing practices that have been identified as outliers. Reviews prior authorizations and determine opportunities for interventions.
Intervention Tracking and Documentation: Tracks contact attempts and contacts per operations procedures. Documents content of and results of consultations as defined in operations procedures; maintains records as required.
Operations: Contributes to the success of the operations of the pharmacy program by assisting with the implementation and management of both written and verbal communications to physicians and prescribers and maintenance of the edits and data elements that support the edits. Is available for consultation on pharmacy-related questions and issues for others within the organization (e.g. health coaches, care managers, etc.). Updates and maintains program engine, coding, consultation sheets and outreach program as needed.
Quality Improvement: Contributes to program improvements by using continuous quality improvement processes, by being proactive in identifying improvement opportunities and by contributing on-going consultation and collaboration with product leaders.
Medical/Clinical: Upholds clinical integrity of pharmaceutical solutions by staying up-to-date on medication information, contributing to the identification of pharmacy program best practices, collaborating with Medical Directors, Medical Dept, and Clinical Dept and provides pharmacy expertise within the organization.
Other duties as assigned. Contributes creative solutions to improve operational efficiency and effectiveness of pharmacy team.

What we're looking for

Minimum of five (5) years of experience in pharmacy benefit management or pharmacy managed care.
Detailed knowledge of Medicaid at the state and federal level.
PharmD.
Ability to communicate succinctly and accurately in both written and verbal English in various group settings from individuals to large groups.
Ability to manage various projects simultaneously.
Experience evaluating healthcare data/outcomes.
Demonstrated leadership ability to drive results across the PBM through team influence and collaboration in a matrixed/shared service organizational model.
Experience with end-to-end pharmacy claims lifecycle, clinical operations, call center management, medication pricing methodologies, NCPDP standards, financial management and managed care statute.
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
Proficient PC abilities (strong knowledge in MS Office), work organization, and problem resolution skills.
Proficient on multiple virtual communication platforms (Microsoft Teams, Skype, Zoom, etc.).