Job Summary:The Senior Clinical Advisor is responsible for utilizing pharmacy acumen, medication expertise, and healthcare payer knowledge related to drug-related prior authorization requirements and medication guidelines to support PA operations (in completing PA reviews), PA technology and automation, consultation on evidence-based guidelines and pharmacy policy, reporting and analytics, and quality management programs. The PBM Pharmacist will collaborate with a team of pharmacy technicians and pharmacists in Pharmacy Operations.
Job Responsibilities (but not limited to):- Works with leadership on special projects such as, but not limited to, unlocking capacity and improving efficiency.
- Works with stakeholders to understand client's product-specific requirements and configuration needs and translate them into technical design specifications and data flow for development, coding, and configuration.
- Coordinates activities as part of the Formulary Development and Maintenance team and recommends measures to improve performance and efficiency.
- Conducts and evaluates research necessary for the development of utilization management strategies.
- Performs clinical reviews of PA, Step Therapy, Quantity Limit, and all other pharmacy utilization requests in accordance with quality, timeliness, and efficiency standards.
- Performs coverage determinations and appeals requests according to criteria guidelines and in compliance with all state and federal regulations, including Medicare and Medicaid.
- Researches and appropriately responds to PA guideline coding and rationale questions.
- Represents RxAdvance in client meetings as well as with external entities as needed.
- Identifies opportunities for continuous quality and efficiency improvements.
- Makes strategic recommendations including benefit design and formulary analysis, provision of clinical drug information, Pharmacy & Therapeutics support and participation, rational drug formulary positioning, online system edits and restrictions, ongoing clinical product evaluations, and client pharmacy benefit utilization and performance trends as required.
- Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical, financial, and operational effectiveness and quality.
- Provides support for internal and external audits and surveys.
Qualifications:Education:- Doctor of Pharmacy (PharmD) degree from an ACPE accredited college is required.
- Managed Care or Clinical Residency program residency highly preferred.
Professional Experience:- 3 - 5 years of recent experience as a senior/lead pharmacist preferably in a PBM or health plan setting.
- Experience with Medicare Part D highly preferred.
- Must have a regard for confidential data and adherence to corporate compliance policy.
- Expert knowledge of the principles and practices of pharmaceutical science, a working knowledge of managed care and policy development as well as working knowledge of state and federal controlled substances and related laws, rules, and regulations.
- Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology.
Licenses/Certifications:- Registered and in good standing with the Board of Registration in Pharmacy.
- Active, non-restricted pharmacist license.
Specialized Skills:- Strong clinical review competency.
- Requires a high degree of initiative and excellent judgment to make decisions regarding clinical pharmacy issues in an extremely complex and often politically charged environment.
- Requires excellent analytical skills necessary for program implementation, maintenance and enhancement and ability to analyze, assess and monitor physicians' prescribing trends and drug utilization patterns for clinical appropriateness and cost-effectiveness with the Plan's operations and goals.
- Highly developed oral/written communication skills, self-motivation, and ability to work independently with minimal supervision are necessary.
- Must be flexible and able to constantly review and reset priorities, often daily, and to handle multiple projects simultaneously.
- Must be able to appropriately identify emergency situations and follow through with the appropriate protocol.
Technical Skills:- Strong PC skills; MS Word, Excel, Access, and Power Point.
