About the Role:The Pharmacist plays a critical role in supporting high-quality, cost-effective medication use for Medicare and Medicaid members enrolled in the health plan. This position ensures compliance with CMS regulations, Star Ratings, HEDIS measures, and state Medicaid requirements while optimizing medication therapy across diverse populations. The pharmacist conducts drug utilization review (DUR), evaluates medication regimens for safety and efficacy, and collaborates with providers to resolve medication-related issues, coverage determinations, appeals and prior authorization needs. The role also includes analyzing pharmacy claims data to identify trends, mitigate risks such as polypharmacy, and support quality improvement initiatives.
Minimum Qualifications:- Doctor of Pharmacy (PharmD) degree from an accredited institution.
- Active pharmacist license in Florida.
- Experience in managed care, Medicare Part D, Medicaid, or health plan pharmacy operations.
- Strong understanding of CMS and Medicaid regulations, MTM requirements and quality measures.
Preferred Qualifications:- Residency training (PGY1 or PGY2) in managed care, ambulatory care, geriatrics, or clinical pharmacy.
- Experience with Medicare Part D benefit design, CMS audits, and Medicaid program requirements.
- Strong communication and conflict-resolution skills for provider and member interactions.
Responsibilities:- Demonstrate commitment to Our Mission and model ILS Experience Standards of Excellence.
- Perform DUR and evaluate medication regimens to identify drug interactions, duplications, contraindications, and adherence issues
- Ensure compliance with CMS Part D regulations, quality measures, and State Medicaid requirements.
- Identify and mitigate risks related to hospice claims, polypharmacy, high-risk medications, and adverse drug events.
- Communicate with prescribers and care teams to resolve medication-related issues, coverage determinations and appeals, and provide clinical recommendations, including formulary alternatives, generics, and cost-effective therapeutic options.
- Support care management, utilization management, and interdisciplinary care teams with medication expertise.
- Analyze pharmacy claims data to identify trends, gaps in care, and opportunities for quality improvement.
- Contribute to CMS audit preparation, reporting, and documentation requirements.
- Participate in quality improvement projects to enhance performance, and member outcomes.
- Support formulary management, prior authorization criteria, and coverage policy development.
- Maintain accurate documentation in MTM platforms, DUR systems, and health plan databases.
- Manage workload efficiently to meet regulatory deadlines and operational timelines.
- Perform all other duties as assigned.
