Clinical Pharmacist

The Clinical Pharmacist will be primarily responsible for the daily operations and decision-making process related to coverage determinations. This includes standard operating procedures and compliance reporting.

The Clinical Pharmacist will also assist in the development, administration and management of the Health Plan’s Medicare Prescription Drug Program, including compliance and oversight of Medicare Part D laws, regulations and reporting requirements, benefit configuration and benefit transition process, and development and implementation of Quality Improvement programs.

The Clinical Pharmacist may participate in the development and oversight of the Part D Drug Formulary and administration of the Drug Utilization Management Program.

This position will work with other constituents, including but not limited to: Pharmacy Director and the Clinical pharmacy team, Member Services, Medical management, IT/Analytics, Compliance, Sales/Marketing and the PBM account team.

Responsibilities:

• Oversee and manage the daily activities and requirements of the Coverage Determination process, claims adjudications system and drug utilization reviews
• Monitor claims system, monthly metrics and quarterly CDAG reports to assure claims adjudication compliance with formulary standards and CMS timeliness guidelines  
• Ensure achievement of organizational and departmental goals through vigorous monitoring of prior auth department metrics
• Perform medical necessity reviews for formulary exceptions and prior authorizations according to the Medicare Part D defined guidelines
• Assists providers with authorization denials in an effort to help them navigate towards a formulary treatment, or provide advisement with the authorization process
• Assist call center pharmacy technicians with clinical questions from prescribers, pharmacies, and/or members
• Oversee and manage email inquiries from Member Services to assist members with questions regarding their medications
• Work with the Pharmacy Benefit Manager (PBM) and formulary manager to manage formulary changes and update the Plan’s website to reflect the most up to date approved CMS versions of the formulary
• Ensure clinical alignment of drug management across medical and pharmacy benefits, including identification of new opportunities for drug management, safety programs, and medical/pharmacy cost savings
• Make recommendations on utilization management edits such as Prior Authorization, Step Therapy and Quantity Limits
• Provide internal professional staff education regarding the pharmacy benefit and formulary
• Assist with the development and implementation of the Pharmacy Department’s Policies and Procedures
• Responsible for pharmacy oversight of member communications including correspondence associated with coverage determination decisions
• Perform other projects, work, and activities as assigned to ensure continuous service to our members

Qualifications:

• Doctor of Pharmacy Degree (PharmD) or Bachelor of Pharmacy Degree (RPh) with extensive clinical experience
• Current and unrestricted State of Florida Pharmacy license. 
• Experience in Medicare Part D plan administration, including, but not limited to Coverage Determinations and formulary administration.
• Completion of, or currently enrolled in, residency program (PGY1) in managed care pharmacy, or pharmacy practice, preferred but not required.

Note:  This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.   

No Third Party Agencies or Submissions Will Be Accepted.   

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP   

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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