Clinical Pharmacist - Managed Care
About The Position
The Clinical Pharmacist is responsible for daily clinical operations and decision-making related to Medicare Part D Coverage Determinations, as well as Formulary maintenance and management. The role supports development, administration, and management of the Health Plan’s Medicare Prescription Drug Program, including compliance with Medicare Part D laws, regulations, and reporting requirements; benefit configuration and transitions; and drug reviews for Pharmacy & Therapeutics Committee meetings. The position assists with Part D formulary oversight and Drug Utilization Management, including weekly new-drug reviews and coding for submission to the Pharmacy Benefit Manager, new contract-year formulary evaluation, and rebate strategy evaluation. The Clinical Pharmacist may review and present new drug entities, new generics, and line extensions to the Plan’s Pharmacy & Therapeutics Committee. The role also supports cost-effective prescribing through prescriber recommendations and education, utilization-data review, identification of savings opportunities and outliers, and deployment and monitoring of cost-reduction strategies. The Clinical Pharmacist works with the Pharmacy Director, Chief Medical Officer, Medical Director, Pharmacy team, Member Services, Utilization Management, IT/Analytics, Finance, Case Management, Provider Relations, Compliance, Sales/Marketing, and the PBM account team. Other projects, work, and activities may be assigned by the Pharmacy Director.
Requirements
- Doctor of Pharmacy (PharmD), or Bachelor of Pharmacy (RPh) with clinical experience, or completion of/current enrollment in a PGY1 residency in managed care pharmacy or pharmacy practice.
- Current and unrestricted State of Florida license.
- Strong computer skills, including Microsoft Office applications such as Outlook, Word, Excel, PowerPoint, and Access.
- Strong communication and presentation skills.
Nice To Haves
- Managed care experience is preferred but not required.
- Part D Coverage Determinations experience is preferred but not required.
- Part D Formulary Management experience is preferred but not required.
- HPMS Formulary Reference File (FRF) submission experience is preferred but not required.
- Programming or reporting software skills.
Responsibilities
- Manage formulary operations, including Formulary Reference File submissions in HPMS.
- Prepare drug monographs for new drug entity reviews.
- Develop educational materials for providers and provide internal professional staff education about the pharmacy benefit and formulary.
- Conduct member medication reviews to identify polypharmacy and inappropriate prescribing, and assist with medication reconciliation.
- Implement and oversee PBM rebate strategies.
- Participate in Pharmacy & Therapeutics Committee meetings, including reviewing and presenting new drug entities, new generics, and line extensions as needed.
- Review CMS model letters.
- Manage Part D Coverage Determinations and monitor cost-effective drug management.
- Perform medical necessity reviews for formulary exceptions and prior authorizations in accordance with Medicare Part D guidelines.
- Work with the PBM and formulary manager to manage formulary changes and update the Plan’s website with the latest CMS-approved formulary versions.
- Recommend cost-effective alternatives to providers and meet with prescribers one-on-one to communicate recommendations.
- Guide pharmacy technicians with clinical questions from prescribers, pharmacies, and members.
- Ensure clinical alignment of drug management across medical and pharmacy benefits, and identify opportunities for drug management, safety programs, and medical/pharmacy cost savings.
- Recommend utilization management edits, including prior authorization, step therapy, and quantity limits.
- Assist with developing and implementing Pharmacy Department policies and procedures.
- Oversee pharmacy-related member communications, including correspondence about coverage determination decisions.
- Review prescription utilization data to identify outliers, trends, and high-cost drug category drivers.
- Develop and implement prescription-drug cost-saving strategies and oversee progress on pharmacy cost-saving initiatives.
- Provide feedback to the Pharmacy Director and other key organizational stakeholders.
- Perform other projects, work, and activities as assigned by the Pharmacy Director.
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What This Job Offers
Job Type
Full-time
Education Level
Ph.D. or professional degree
