Job Description

Your Role

The Prior Authorization (PA) team utilizes clinical knowledge to review authorization requests for coverage under the outpatient pharmacy benefit. The Pharmacist, Consultant will work as part of the pharmacy benefit Prior Authorization (PA) team to support the Blue Shield of California (BSC) Pharmacy and Therapeutics Committee (P&T) by ensuring that evidence based clinical decisions are implemented appropriately to provide a high-quality and cost-effective pharmacy benefit. The Pharmacist, Consultant (Drug Utilization Review Pharmacist) will report to the Drug Utilization Review (DUR) Pharmacist Manager.

Responsibilities

Your Work

In this role, you will:

• Support the clinical and operational implementation of P&T approved policies for the pharmacy benefit, for both the Commercial and Medicare lines of business
• Apply clinical expertise to PA reviews and work collaboratively with the PA and Call Center Teams to support access to safe, efficacious, and medically necessary medications
• Operate in compliance with all regulatory and accreditation requirements to ensure all requests are reviewed within regulatory required timeframes
• Serve as a resource to internal and external constituents regarding the Blue Shield drug formulary, medication policies and appropriate drug use
• Embrace BSC values by answering clinical and operational questions, participating in group discussions, and supporting other team members while working towards a collective goal
• Use clear and concise communications and on-brand messaging when communicating with providers or members
• Follow all corporate policies and procedures
• Operate in compliance with all regulatory and accreditation requirements, and corporate policies and procedures regarding the support access to safe, efficacious, and medically necessary medications
• Assist in preparing materials for audits and reports; complete projects as assigned

Qualifications

Your Knowledge and Experience

• Requires a Doctor of Pharmacy (PharmD) degree
• Requires a currently active and unrestricted California Registered Pharmacist (RPh) license
• Requires at least 2 years of experience in clinical pharmacy
• Previous experience working at a health plan is preferred
• Prior authorization experience is preferred
• Excellent oral and written communication skills
• Thorough knowledge of therapeutic use of medications

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come into the office based on business needs.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.