Job Summary
Job Summary
Under the direction of the Pharmacy Utilization Management (UM) Supervisor, the Clinical Pharmacist is responsible for reviewing, processing and managing the daily caseload of pharmacy prior authorization (PA) requests for coverage determinations (CD), and exceptions. The Clinical Pharmacist ensures timely disposition of reviews for CD and exceptions by adherence to established timeframes. The Clinical Pharmacist consults as required with THP Medical Directors (MD) on prior authorization that fails to meet drug prior authorization (PA) criteria for coverage.
Job Description
• Performs case reviews in automated prior authorization (Auto PA) tools and guides the case through the entire process to either approval or denial to ensure all coverage determinations and notices are consistent with applicable regulatory and accreditation requirements and turnaround times
• Provides all aspects of clinical support needed to perform drug prior authorization (PA) requests and consults as required with THP Medical Directors (MD) on cases that fail to meet coverage criteria
• Communicates daily with members, providers and other external customers regarding status and disposition of cases
• Oversees and addresses any quality issues with pharmacy technicians and confer with other clinical pharmacist on review questions
• Communicate with UM staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage determinations within timelines developed by all accrediting and regulatory guidelines
• Facilitates communication between Pharmacy UM department and other internal Tufts Health Plan departments by acting as a liaison or committee member on the development or implementation of new programs
• Performs other roles/duties and projects as assigned by the Pharmacy UM Supervisor or Manager
Requirements
EDUCATION: (Minimum education & certifications required)
• A minimum of a Bachelor of Science degree in Pharmacy or PharmD
• Current registration and good standing with the Board of Pharmacy
EXPERIENCE: (Years of experience)
• A minimum of 3 years full-time experience as a pharmacist, preferably PBM and/or managed care setting
• Expert knowledge of the principles and practices of pharmaceutical science. Working knowledge of Federal and state controlled substance and pharmacy laws, rules and regulations
• Knowledge of drug coding (NDC, GCN, GPI and USC) and NCPDP claims adjudication systems
• Previous working knowledge of MedHOK, RxClaim, CCMS and CAS system a plus
• Knowledge of or experience with Medicare Part B & D, Medicaid and Drug Utilization Management
• Prior authorization experience, including reviewing drug use criteria for medication approval
SKILL REQUIREMENTS:
• Requires analytical ability to independently research/ summarize data on drug utilization and spend
• Excellent written and verbal communication skills
• Strong PC skills with MS Office (Word, Excel, PowerPoint & Access) and ability to learn/use new database and reporting applications
• High degree of professionalism and confidence
• Ability to recognize politically sensitive issues and utilize diplomacy
• Ability to interact effectively with all levels of management
• Must be self-motivated and capable of working independently with minimal supervision
• Must be capable of organizing, facilitating and managing several projects simultaneously
• Must be flexible and able to constantly review and reset priorities; often daily
Job Description
Key Responsibilities/Duties – what you will be doing (top five):
- Provides subject matter expertise for the integrated team and supports the member’s medication management needs
- Provides clinical pharmacy services and support to members and providers
- Manages members with complex pharmaceutical needs in collaboration with the care team
- Completes medication review and reconciliation for members with complex medication regimen
- Serves as the medication expert for patients, providers, and care team members
- Works closely with other members of the care team, members’ family, and caregivers
- Collaborates with care team in care management, coordination of care and care planning in the transitions of care
- Works closely with other members of the care team, members’ family, and caregivers
- Documents appropriately and timely in the care management information system
- Participates in risk management activities, including identifying and communicating issues of risk in a timely manner
- Participates in case reviews and care team huddles
- Serves as a liaison between members, providers, and medication management service providers
- Provides administrative support and plays a key role in performance management
- Collects and analyzes related data, as needed.
- Participates in risk management activities, including identifying and communicating issues of risk in a timely manner
- Adheres to departmental/organizational policies and procedures
- Complies with established metrics for performance, adheres to documentation and workflow standards
- Maintains HIPPA standards and confidentiality of protected health information
- Represents Point32Health in a professional manner and participates in the ongoing development and growth of the department and overall organization
- Perform other duties and projects as assigned.
Qualifications – what you need to perform the job
Certification and Licensure
- Licensed to practice pharmacy in Massachusetts with pharmacy degree required
- Current and valid Massachusetts pharmacist license
- Certification by the Board of Pharmacy Specialties in a relevant area of pharmacy practice (e.g., BCACP, BCGP, BCPP, BCPS).
Education
- Required (minimum): Doctor of Pharmacy (PharmD)
- Preferred: PharmD from an ACPE-accredited school of pharmacy strongly desired
Experience
- Required (minimum): 5 or greater years of progressive clinical pharmacy experience in managed care, facility, and retail setting. 2 years of related clinical experience in an ambulatory setting. Extensive knowledge of Medicare and MassHealth formularies. Care management, high-risk population, and/or transitions of care experience
- Preferred:
Skill Requirements
- Strong interpersonal skills with ability to manage build relationships and influence member behavior
- Autonomous practitioner with strong critical thinking skills
- Articulate with ability to present clinical and administrative information concisely
- Independent problem-solving ability with ability to manage conflict and build consensus
- Organizational skills with ability to prioritize based on deliverable timelines, member needs and contract requirements
- Ability to practice in an interdisciplinary team-based model
Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):
- Travel to members residence and outside meetings
- Must be able to work under normal office conditions and work from home as required.
- Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
- May be required to work additional hours beyond standard work schedule.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.
Salary Range
$110,680.66 -$166,020.98
Compensation & Total Rewards Overview
The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.
Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:
Medical, dental and vision coverage
Retirement plans
Paid time off
Employer-paid life and disability insurance with additional buy-up coverage options
Tuition program
Well-being benefits
Full suite of benefits to support career development, individual & family health, and financial health
For more details on our total rewards programs, visit
