Staff Clinical Pharmacist (Tuesday - Saturday) - Jefferson Health Plan

Jefferson Health Plans • Philadelphia, PA

3d

About The Position

Working under minimal supervision, the Clinical Pharmacist is responsible for managing the prescription benefit program for all lines of business for Health Partners. The incumbent uses clinical pharmacy expertise as well as approved criteria in administering the prescription prior authorization program. Other responsibilities include: suggesting adherence to approved formularies to providers, supporting Medical Directors in case reviews overseeing the recipient restriction program (RRP) and monitoring appropriate drug utilization. Incumbents actively participate in physician education & outreach programs, represents the pharmacy department at internal and external committees and perform claims analysis for drug utilization review (DUR), related to fraud, abuse, and/or over/under-utilization and drug adherence. Able to work in a constant state of alertness and safe manner Review prior authorization requests to make coverage determinations to ensure clinical appropriateness based on pharmacy guidelines and established clinical criteria. Develop and prepare clinical research analysis for Pharmacy and Therapeutics (P&T) committee presentations. Educate and support Pharmacy Technicians on pharmacy benefit issues both clinical and non-clinical. Create clinical criteria for new and existing pharmaceuticals following best practices and prepare criteria documents for submission to regulatory agencies. Respond to pharmacy hotline phone calls from physicians, discussing patient care dosing and safe and effective formulary alternatives, and phone calls from pharmacy providers discussing safe and effective formulary alternatives, processing errors (i.e., eligibility, plans limits exceeded, NDC not covered, refill too soon, etc.) and resolving reimbursement issues. Gather all necessary clinical (previous medication history) and pharmacoeconomically information including contacting physician or nurse for previous medical history and/or specific required lab tests as deemed appropriate, for presentation to a Medical Director for prior authorization case review. Conduct clinical DUR on pharmacy claims and make recommendations for recipient restriction program or quality management. Monitor activities of the existing restricted members. Assist management in physician, member and pharmacy network DUR analysis and other departmental reports. Interact with other departments including Member Relations, Special Needs, Complaints and Grievances, Disease Management, and Utilization Management, in resolving pharmacy related issues along with identify areas of potential operational improvement with other departments. Assure compliance to all regulatory requirements associated with DOH, DPW and NCQA. Work with external pharmacy vendors ensuring appropriate quality of care and coordination of care. Research and analyze new pharmaceuticals or new indications for existing pharmaceuticals. Work within the Pharmacy Department to create and maintain an updated formulary with appropriate FDA safety, quantity, and quality edits. Work with management and the formulary pharmacist on formulary management, utilization review, prior authorization, Specialty Medication management, pharmacy audit process and other functions within the pharmacy department Assure compliance with departmental policies and procedures and processes. Will perform other duties as assigned.

Requirements

• Pharmacy degree from accredited school, Pharm. D., R.Ph,or BS Pharmacy
• Excellent written and oral communication skills
• Competency with Microsoft Office Suite including: Word, Excel, PowerPoint skills and database knowledge
• Self-motivated and team player with ability to direct projects and assignments.
• Strong presentation ability
• Able to work in a constant state of alertness and safe manner

Nice To Haves

• 2-3 years clinical pharmacy experience
• 1-2 years prior managed care experience

Responsibilities

• Review prior authorization requests to make coverage determinations to ensure clinical appropriateness based on pharmacy guidelines and established clinical criteria.
• Develop and prepare clinical research analysis for Pharmacy and Therapeutics (P&T) committee presentations.
• Educate and support Pharmacy Technicians on pharmacy benefit issues both clinical and non-clinical.
• Create clinical criteria for new and existing pharmaceuticals following best practices and prepare criteria documents for submission to regulatory agencies.
• Respond to pharmacy hotline phone calls from physicians, discussing patient care dosing and safe and effective formulary alternatives, and phone calls from pharmacy providers discussing safe and effective formulary alternatives, processing errors (i.e., eligibility, plans limits exceeded, NDC not covered, refill too soon, etc.) and resolving reimbursement issues.
• Gather all necessary clinical (previous medication history) and pharmacoeconomically information including contacting physician or nurse for previous medical history and/or specific required lab tests as deemed appropriate, for presentation to a Medical Director for prior authorization case review.
• Conduct clinical DUR on pharmacy claims and make recommendations for recipient restriction program or quality management.
• Monitor activities of the existing restricted members.
• Assist management in physician, member and pharmacy network DUR analysis and other departmental reports.
• Interact with other departments including Member Relations, Special Needs, Complaints and Grievances, Disease Management, and Utilization Management, in resolving pharmacy related issues along with identify areas of potential operational improvement with other departments.
• Assure compliance to all regulatory requirements associated with DOH, DPW and NCQA.
• Work with external pharmacy vendors ensuring appropriate quality of care and coordination of care.
• Research and analyze new pharmaceuticals or new indications for existing pharmaceuticals.
• Work within the Pharmacy Department to create and maintain an updated formulary with appropriate FDA safety, quantity, and quality edits.
• Work with management and the formulary pharmacist on formulary management, utilization review, prior authorization, Specialty Medication management, pharmacy audit process and other functions within the pharmacy department
• Assure compliance with departmental policies and procedures and processes.
• Will perform other duties as assigned.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level