JOB SUMMARY:The Clinical Pharmacist - Medical Drug Policy & Oversight serves as a clinical subject matter expert supporting the organization's medical drug management program. This position develops and maintains evidence-based medical drug policies, monitors new and emerging therapies, coordinates clinical criteria with the Pharmacy Benefit Manager (PBM), and ensures medical drug strategies are implemented accurately and consistently.
The pharmacist also provides clinical oversight of utilization management activities and delegated vendors, evaluates clinical and financial opportunities for medical drug management, supports implementation, and leads provider education and academic detailing initiatives.
KEY RESPONSIBILITIES:- Lead the development, implementation, maintenance, and annual review of evidence-based medical drug policies and clinical criteria using FDA labeling, clinical literature, treatment guidelines, regulatory requirements, and emerging evidence.
- Coordinate medical drug criteria and formulary strategies with the Pharmacy Benefit Manager (PBM) to promote alignment across pharmacy and medical benefits.
- Monitor new drug approvals, indications, biosimilars, oncology therapies, and emerging treatments; assess clinical and financial impact and evaluate opportunities for prior authorization, step therapy, preferred products, formulary management, and other utilization management strategies, including potential return on investment.
- Monitor and evaluate Utilization Management pharmacists' clinical decisions to ensure consistent and accurate interpretation and application of medical drug policies, clinical criteria, and regulatory requirements; identify trends and opportunities for improvement and provide clinical education and feedback to promote quality and consistency.
- Serve as a clinical resource for complex policy interpretation, coverage criteria, and medical drug utilization management questions.
- Provide clinical oversight of delegated vendors performing oncology and specialty drug reviews, including monitoring clinical consistency, performance, and adherence to established criteria.
- Evaluate utilization trends, regulatory changes, clinical evidence, and program performance to identify and implement opportunities to improve medical drug utilization management programs.
- Ensure new and revised medical drug policies and clinical decisions are accurately translated into operational workflows and system configuration.
- Develop and support provider education and academic detailing by identifying patient-specific opportunities to optimize therapy and promote cost-effective, quality care, while analyzing data to track program impact, measure outcomes, and identify opportunities for improvement.
- Collaborate with Medical Directors, Pharmacy leadership, Utilization Management, PBM and vendor partners, Finance, Provider Relations, Claims, IT, and other stakeholders.
- Support clinical governance committees and other pharmacy initiatives as needed.
- Perform other job-related duties as required or assigned.
QUALIFICATIONS:
- Strong knowledge of managed care pharmacy, medical drug utilization management, and formulary management principles.
- Demonstrated understanding of Medicare, Commercial, medical benefit, and pharmacy benefit management operations.
- Ability to evaluate and apply clinical literature, FDA labeling, treatment guidelines, and regulatory requirements to develop evidence-based medical drug policies and clinical criteria.
- Knowledge of specialty medications, biologics, medical injectables, HCPCS/J-codes, and medical benefit drug billing.
- Strong analytical, organizational, critical thinking, and decision-making skills.
- Excellent written, verbal, presentation, and collaboration skills.
- Proficiency with Microsoft Office applications and pharmacy information systems.
- Ability to work remotely with travel to the office as needed.
- Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE:- Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy from an accredited School of Pharmacy.
- Active, unrestricted pharmacist license in any United States jurisdiction.
- Minimum of five years of clinical pharmacy experience in managed care pharmacy, health plan pharmacy, pharmacy benefit management, specialty pharmacy, hospital pharmacy, or a related clinical practice setting.
- Experience with medical injectable and specialty drug utilization management preferred.
- Experience developing clinical policies or coverage criteria and evaluating medical drug therapies preferred.
- Experience with oncology medications, vendor oversight, formulary management, data analysis, or provider education preferred.
