This position is responsible for leading the medical policy efforts of prescription drugs, which includes strategy development, implementation, build, maintenance, quality review, and measurement of the prior authorization program.  This position also serves as a liaison to the clinical appeals area and serves as lead pharmacist on the Pharmacy and Therapeutics Committee.

• This role does not manage people
• This role reports to this job: Manager, Pharmacy Medical Policy & Specialty Drug Management.
• Necessary Contacts: To do this job effectively, the incumbent has to be in contact with:
  All levels of BCBSLA pharmacy department, and clinical areas of Medical Management, PBM clinical personnel, and e-hosting formulary vendor personnel. Incumbents dedicated to Medical Policy also have contact with the Lead Medical Director for Medical Policy as well as BCBSLA’s Medical Policy, Clinical Appeals, Professional and Facility Reimbursement, and Legal departments.

• Doctorate of Pharmacy required or
• Bachelor's Degree in Pharmacy required

• 1 year of experience working in clinical pharmacy roles and supporting P&T Committee and/or drug information activities required
• 1 year of experience in managed care preferred
• Experience with software programs such as Word and Excel is a must and knowledge of PowerPoint preferred

• Must have proficiency in pharmacology, therapeutics and knowledge of disease management programs for the purpose of supporting the clinical aspects of this job.
• Must possess strong interpersonal, organizational, oral/written communication skills in addition to strong clinical skills.

• Current pharmacy license in good standing required
• Participation in ASHP or AMCP-accredited residency program preferred

• Serve as companywide subject matter expert regarding specialty drug management strategies of medications covered under both the pharmacy and medical benefits, including specialty pharmacy pipeline monitoring to identify new products that are expected to have major clinical and financial impacts on drug trend, for the purpose of ensuring BCBSLA’s coverage of specialty drugs are current, clinically sound, and cost-effective.
• Serves as lead author of medical policy clinical criteria which includes the development, updating, and maintenance of decision tree logic used to support phone, fax, and web-based authorizations; includes consistency of authorization requirements within therapy classes; and includes monitoring the results of the authorization process (i.e., authorization, denial, and appeal rates) for the purpose of ensuring BCBSLA’s drug utilization management programs are current, clinically sound, efficient, and cost-effective.
• Serve as lead BCBSLA pharmacist to the Pharmacy and Therapeutics Committee ; pharmacist liaison to the Clinical Appeal areas; leads review and discussion of drugs that are new to market, have new indications, or updated safety profiles and primarily accountable for change management functions as a result of the Annual Formulary Update process.
• Collaborates with pharmacy reporting and analytics for the purpose of measuring utilization management program effectiveness, identifying medical and pharmacy drug dosing and utilization management opportunities, managing medical drug rebate programs, and providing rebate opportunity assessments.
• Responsible for maintenance and updating of self-administered drug list programming for purpose of ensuring that drugs intended to be self-administered by patients are not routinely reimbursed under the medical benefit.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.