Clinical Pharmacist - Prior Authorization/Managed Care - Western Health Advantage

Clinical Pharmacists function in many areas within the pharmacy department. Clinical Pharmacists perform the clinical review of medical and outpatient pharmacy Utilization Management (UM) cases, using their clinical acumen and benefit information into consideration when issuing a decision. Clinical Pharmacists are charged with adhering to all regulations in their decision making, including NCQA, DMHC and Board of Pharmacy. They need to communicate effectively with network providers and staff, discussing member prior authorizations and decision rationale. Clinical Pharmacists are responsible for formulary development activities for multiple lines of business including leading internal Pharmacy and Therapeutics Committee (P&T) efforts, in addition to serving as members on this committee. Efforts include drug pipeline management, recommendations, monograph creation, and policy writing while maintaining and updating pharmacy UM policies. They provide clinical oversight for the accuracy of claims adjudication, as needed. Clinical Pharmacists manage new-to-market products, National Drug Codes (NDCs), and communication with the PBM’s Clinical Consultant. Clinical Pharmacists support the management and updates of the preferred drug list. Clinical Pharmacists support implementation of clinical programs, revision of drug policies and guidelines and completion of therapeutic category reviews. Clinical Pharmacists also provide recommendations on process improvement to the Director of Pharmacy and Pharmacy Manager. Clinical Pharmacists report directly to the Pharmacy Manager.

Representative Duties:

• Develop and update clinical pharmacy UM criteria for review of both outpatient pharmacy and office administered medications.

• Monitor and review prior authorization (PA) requests for medications; perform all duties related to drug utilization review in compliance with regulatory requirements.

• Research drug information to maintain current, accurate drug knowledge and disease state understanding for application to PA reviews.

• Analyze pharmacy cost of care, trends, and coordinate the development of appropriate use protocols, programs, and guidelines.

• Provide support to the P&T Committee through committee participation and project completion, including therapeutic category reviews, drug reviews, criteria updates, record keeping, and other analyses, as needed.

• Participate in the development and implementation of clinical quality improvement programs in coordination with the Medical Management department, Pharmacy Benefit Management (PBM), and Medical Groups.

• Interface with Medical Groups and Prescribers to educate and inform them of pharmacy program initiatives and cost-effective prescribing options, as needed.

• Work closely with the PBM to support coding and management of newly released or existing drug products identified through the P&T committee and routine audits of formulary documents.

• Audit and update the WHA formulary drug list and Pharmacy PA Criteria website.

• Precept or participate with pharmacy students on their introductory or advanced pharmacy practice experience rotations with affiliated pharmacy schools, as needed.

• Assist the Pharmacy Director with accreditation audits by the Department of Managed Health Care (DMHC) regulatory and National Committee of Quality Assurance (NCQA), as needed.

• Provide clinical guidance and support to various internal departments that require clinical pharmacist intervention.

• Support development of pharmacy policy procedures, training material, and desk level procedures.

• Work with the Pharmacy Manager to ensure there is appropriate coverage during holidays and Friday night to ensure all cases are completed to comply with regulatory requirements

• Perform other duties and special projects as assigned by the Chief Medical Officer, Pharmacy Director, and Pharmacy Manager.

Qualifications:

• Must have a Doctor of Pharmacy (PharmD) degree or equivalent education that satisfies California pharmacist license requirements. Pharmacy Residency training is preferred.

• Must have a current, valid California Pharmacist license in good standing and must be maintained throughout employment.

• Four years of mail order, retail, or hospital experience.

• Two years of managed care pharmacy experience, PBM, Health Plan, or delegated Medical Group is preferred.

• Proficient in the evaluation of drug literature, clinical trial data, and electronic database information (e.g., UpToDate, DrugDex, Clinical Pharmacology, NCCN, etc.).

• Strong clinical and analytical background for specialty medications is preferred.

• Experience writing drug monographs or prior authorization criteria.

• Formulary management experience is preferred.

• Experience writing with business correspondence style.

• Proficient computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc.

• Must be able to speak, read, write, and understand the primary language(s) used in the workplace

Salary:

$115,000.00-$130,000.00 Annually

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.

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