Provides professional and clinical expertise for Pharmacy Services’ clients in making clinical decisions based on best practices in applying evidence based medicine evaluations to determine the best quality medication choices that represent the best value in efficacy and safety. Assists in planning, developing, and implementing clinical strategies for Pharmacy Services’ clients with respect to formulary management, drug utilization management, medication therapy management programs, quality initiatives and drug information and education. Responsible for conducting peer clinical reviews.
Responsibilities & Requirements
- Responsible for delivering high quality clinical services for Pharmacy Services’ clients for Medication Benefit Management.
- Responsible for conducting peer clinical reviews. (The medical director has the responsibility to determine that the peer clinical reviewers are qualified to render a clinical opinion for items under review.)
- Responsible for peer to peer conversations.
- Works independently within framework and guidelines to evaluate intangibles associated with cost-containment and quality improvement of prescription drug charges.
- Provides creative thinking and leadership in accomplishing goals of quality improvement and cost-effective prescription drug programs.
- Collects, analyzes, interprets, and forecasts health care cost information based on current prescribing patterns based on medication utilizationreports.
- Develops position papers, medication coverage policies, formulary monographs and class reviews, and formulary coverage recommendations based on critical appraisal of the scientific literature and input from practicing physicians to ensure optimal clinical outcomes at most cost-effective level.
- Provides clinical decision-making based on best practice in applying evidence-based medicine process in determining medications that have best value for efficacy and safety.
- Presents and/or communicates clinical positions on medication analysis in clear, concise manner to Pharmacy Services’ clients.
- Develops and provides educational materials and correspondences to members to inform them about medication coverage choices, comparative effectiveness, and coverage determinations.
- Presents formulary and medication coverage policy considerations to internal and external decision-making bodies such as the Pharmacy and Therapeutics Committee and Medication Policy Group.
- Participates in effective relationship management with Pharmacy Services’ clients that include members, medical directors, account representatives, case managers, customer services, appeals/grievance panels, and external providers.
Provide coverage recommendations for medications subject to prior authorization, appeals, retrospective claim reviews, and audits based on applicable medication coverage policies, member benefit contracts, and provider contracts.
Competencies and Knowledge:
- Strong clinical pharmacy background with ability to demonstrate clinical therapy skills and knowledge in a clinical care setting.
- Demonstrated success in managing professional relationships in a managed care system, medical group, hospital, or related organizations.
- Strong knowledge of prepaid health care economics and financing; pharmaceutical/healthcare industry dynamics, and provider contracting strategies, techniques, and processes.
- Strong knowledge of health care economics and financing; health care/pharmaceutical industry dynamics; and pharmacy/provider service reimbursement of medications.
- Demonstrated success in managing professional business relationships in a managed care system, medical group, hospital, or related business in health care delivery industry.
- Excellent verbal and written communication skills; strong business analytical skills and abilities; strong project management and coordination ability; ability to function effectively as a management team member.
- Knowledge of: Health Plan and benefit design structures and application; Medicare/CMS regulations and applicability in administering the Medicare Product; Pharmaceutical products, including orals, injectables, infusion products, and chemotherapy; health care coding and payment systems (such as ICD-9, CPT, HCPCS, NDC); state and federal laws and rules regarding the practice of pharmacy and regulation of health care industry practices, such as DOLI, PPACA and HIPAA; Compliance related activities, legislative and regulatory activities, health insurance operations, or legal research helpful.
Normally to be proficient in the competencies listed above:
Clinical Pharmacist Consultant would have a Bachelor’s degree in Pharmacy or related field and four years of experience in clinical acute care/hospital setting or equivalent combination of education and experience.
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. We are an equal opportunity employer dedicated to workforcediversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check is required.
Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members more than 90 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you’re seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers’ engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
Requisition ID 2017-23674