Clinical Pharmacist - AMA Dual

CVS Health

3d•$106,200 - $225,000•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Clinical Pharmacist - AMA Dual will be a multi-dimensional position; the primary areas of responsibility will include the following: 1. Complete Clinical Reviews and provide a determination of Medicare-Medicaid Coverage Determination/Redetermination, Medical Review, Global Exception etc. by reviewing all requests which are not clearly approvable based on specified criteria (algorithms). 2. Responsible for support and input to clinical programs such as: Health Management (IDT), Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high quality, cost effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place. 3. Continually monitor the quality and efficiency of the Prior Authorization process including coverage criteria, denial language, and communication with prescribers and members. Provide recommendations to physicians to improve medication regimens as appropriate. 4. Provide input to clinical content of new programs and for maintenance of existing programs. 5. Complete all annual NCQA, Aetna required and Quarterly IRR training requirements. 6. Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee. 7. Assists Member Services and other internal customers in responding to and resolving pharmacy-related inquiries from members (NCQA Requirement). 8. Maintain open lines of communication with other functional areas/departments. 9. Responsible for staying current with clinical literature and guidelines and relaying those to the program development core teams. This is a remote role open to qualified candidates within the United States. Team hours are M-F, 6:30am-6pm AZ time and colleague will be scheduled a regular shift during this timeframe once training is complete. On-call or weekend hours may be required post-training to meet business needs, current rotation requirement is every 5th weekend.

Requirements

Demonstrated proficiency in Microsoft Excel, Word, Outlook, and SharePoint
Superior written and verbal communication skills
1+ year managed care pharmacist experience (Medicaid and/or Medicare) and/or completion of PGY1 managed care residency
1+ year of previous clinical pharmacy experience
Demonstrated knowledge of clinical program components, formulary designs, and prescription benefit trends
Active Registered Pharmacist license is required in State of Residence

Nice To Haves

3+ years of experience working as a licensed Pharmacist
3+ years managed care experience is highly desirable, but not required
RxClaim experience
Proven success in a fast-paced, remote working environment

Responsibilities

Complete Clinical Reviews and provide a determination of Medicare-Medicaid Coverage Determination/Redetermination, Medical Review, Global Exception etc. by reviewing all requests which are not clearly approvable based on specified criteria (algorithms).
Responsible for support and input to clinical programs such as: Health Management (IDT), Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high quality, cost effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place.
Continually monitor the quality and efficiency of the Prior Authorization process including coverage criteria, denial language, and communication with prescribers and members. Provide recommendations to physicians to improve medication regimens as appropriate.
Provide input to clinical content of new programs and for maintenance of existing programs.
Complete all annual NCQA, Aetna required and Quarterly IRR training requirements.
Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee.
Assists Member Services and other internal customers in responding to and resolving pharmacy-related inquiries from members (NCQA Requirement).
Maintain open lines of communication with other functional areas/departments.
Responsible for staying current with clinical literature and guidelines and relaying those to the program development core teams.