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Pharmacist is responsible for conducting coverage determination reviews for clinically complex cases and for any potential denials in conjunction with pharmacist/prior authorization team. Pharmacist will also be responsible for conducting Medication Therapy Management (MTM) reviews and interventions as appropriate in conjunction with MTM Pharmacist and MTM Technician. Position will also be responsible for assisting with review and preparation of documentation for Bravo Health’s Pharmacy and Therapeutics (P&T) Committee, including preparation/collection of monographs for new drug reviews.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
· Perform coverage determinations for prescription drugs against established criteria for Level II (Clinically Complex) cases and any prior authorization requests that may result in a denial of coverage.
· Share on-call duties with clinical pharmacy team for urgent coverage determination requests.
· Conduct occasional clinical literature searches to support the coverage determination function for Level II cases as needed.
· Communicate with prescribers and other practitioners regarding coverage determinations as needed, including requests for additional information and prior authorization decisions.
· Support departmental MTM activities including initial patient assessment, drug history review, development of treatment intervention plans, and periodic intervention with patients and prescribers as appropriate.
· Develop and support various clinical initiatives related to member/prescriber education and medication compliance.
· Support pharmacy-related activities with Bravo Health’s Health Services team, Medical Directors, and other stakeholders within the health plans.
· Develop monographs for new drugs in conjunction with clinical pharmacy team, prescription benefit manager, and other parties for presentation and review at quarterly Pharmacy & Therapeutics (P&T) Committee meetings.
· Assist with reviewing various data concerning drug utilization patterns and trends; provide analyses and conclusions geared to non-pharmacist audiences
· Support departmental activities related to Quality Improvement (QI) activities, including participation in annual plan development and review, development and presentation of annual studies, and other corporate QI activities (e.g. NCQA accreditation).
· Perform other duties as may be assigned by Vice President, Clinical Pharmacy or Senior Vice President, Part D.
Doctor of Pharmacy preferred; will consider RPh with strong clinical experience
Must have at least two (2) years clinical pharmacy experience involving patient interaction; prior managed pharmacy experience a significant plus
· Must be able provide clear and effective direction to other team members involved in coverage determination functions;
· Must have strong writing skills to support clinical documentation, policy and procedure development, and report generation for various clinical functions;
· Must be able to present to various internal and external audiences as needed (e.g. QI Committee, P&T Committee, external QI organizations, etc.).
Must be able to juggle and solve multiple problems in a dynamic environment balancing both clinical and business needs.
PHYSICAL DEMANDS/WORK ENVIRONMENT:
Standard office environment; occasional travel to affiliated plan offices and service areas may be required.
Must be able to demonstrate independent decision-making supported by existing guidelines; must be able to exercise good
Must be familiar with Windows environment and associated Microsoft Office applications (MS-Word, MS Excel, etc.). Past experience with a PBM data warehouse or reporting package a major plus. Retail pharmacy software experience also a plus.
Are you a returning applicant?
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