Clinical Operations Pharmacist (44572)

The Clinical Operations Pharmacist works in conjunction with the Clinical Program Pharmacist and Medical Management teams to review medication utilization and develop/implement initiatives to ensure appropriate drug therapy prior authorization decisions are consistent with covered benefits, quality of care and medical necessity. Work is focused at both the individual patient and "population based" therapy level. In addition, he/she supports the department by coordinating the activities of the Senior Manager of Regulatory and Pharmacy Operations and formulary advisory committees. He/she may also participate in care management activities and provide backup coverage to the Senior Manager as needed.

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:

• Responsible for the pharmacy utilization management (UM) reviews. Uses clinical expertise and independent judgment to evaluate prior authorization (PA) to determine if request meets established PA criteria, clinical medical policies, or clinical medical necessity (CMN) criteria.
• Responsible to maintain and support pharmacy UM programs and provide implementation support for formulary management decisions and clinical policies. Assists with the creation, maintenance of administrative, and utilization management policies.
• Support medical cost savings strategy including, but not limited to, executing UM reviews for high cost medications and evaluate complex treatment plans are medically appropriate. Make clinical UM recommendations of these for leadership level review.
• Engages ordering providers in discussion related to CMN. Documents all aspects of PA review process within PA software application per NCQA standards.
• Provides pharmacy-related customer service to external and internal parties. Serves as drug information resource for internal departments (e.g., Care Management, Medical Directors, Grievance and Appeals Unit).
• Provide ongoing leadership & support to Pharmacy Technicians in order to ensure that day-to-day service and production goals are met.
• Provide peer trainings and assist with onboarding of new employees.
• Maintains current knowledge of and ensures compliance with government and federal regulations. Commits to regulatory adherence to meet turnaround time requirements set by our State and Federal regulators.
• Committed to evaluate quality controls. Responsible to audit cases to ensure compliance of regulatory requirements and to evaluate quality improvement opportunities.
• Follows best practices to maintain high production and quality standards to deliver excellent provider, member, and employee experience.
• Continuously look for ways to streamline and improve operational workflows.
• Effective planning, organizational and decision-making skills; ability to handle multiple high priority projects with competing deadlines
• Supports the documentation of processes required for day-to-day operations.
• Demonstrates a strong understanding of all lines of business (LOB) including benefit design and regulatory requirements per LOB.
• Performs other duties as assigned that may include, but not limited to:
• Oversight of daily operational duties and work with senior leadership to de-escalate issues
• Support departmental projects when assigned
• Maintain daily, weekly, monthly, quarterly and annual operational metrics to ensure optimal and comprehensive operational efficiency and accuracy. Analyze, report, trend, solution and escalate findings from the routine reports and provide education to pharmacist staff on areas of opportunities.
• Engages with pharmacy department vendors on operational items to ensure appropriate escalation and resolution.