Clinical Review Pharmacist

ChenMed

1d•$118,062 - $168,658•Hybrid

About The Position

The Clinical Review Pharmacist works to ensure that ChenMed members have access to all medically necessary prescription drugs, and those drugs are used in a cost-effective, safe manner. The incumbent completes prior authorizations for internal expert peer discussions (EPD) on high-cost medications to control appropriate medication use, following guidelines created by the organization. Additionally, they are involved in formulary management (such as reviewing prior authorization requirements, reviewing drug/provider utilization patterns and pharmacy costs management), clinical pharmacy services (such as therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety and medication use policies).

Requirements

Doctorate of Pharmacy (PharmD) required
Must have a License that is in good standing
Minimum one (1) year of pharmacy experience
Minimum one (1) year of utilization review experience preferred
Excellent analytical and deductive reasoning skills; detail oriented
Good judgement and problem-solving skills
Knowledge of and experience with state and federal insurance programs
Familiarity with appropriate local, state, and federal pharmacy laws and regulations
Ability to work effectively independently and as part of a team
Ability to communicate effectively with staff, management, executives and patients/members
Strong organization and time management skills and multi-tasking abilities
Written and verbal fluency in English; bilingual preferred
Proficient in the use of Microsoft Office products such as Outlook, Excel, Word and PowerPoint
Willingness to travel locally up to 50% of the time; flexible to work evening, weekends and/or holidays as needed
This job requires use and exercise of independent judgment

Nice To Haves

Pharmacy residency training is preferred, but not required
Experience in a managed care setting (HMO, MSO, PBM) is a plus
Medicare Part D or Medicaid experience, along with managed care experience

Responsibilities

Reviews coverage determinations and appeals in a timely, compliant, and accurate manner.
Ensures compliance with the coverage determination and appeals process.
Acts as a liaison between ChenMed and its patients with respect to the clinical guidelines we practice.
Serves as the formulary expert for the therapeutic class they are reviewing.
Contributes to projects aimed at improving STAR ratings, HEDIS, CAHPS, and other quality metrics.
Assists with clinical questions and phone calls from prescribers, pharmacies and/or ChenMed members.
Develops, implements and maintains pharmacy cost control and quality initiatives under the direction of leadership and guidelines.
Monitors drug utilization and assists Pharmacy leadership team in understanding quality and cost control issues.
Acts as a liaison between ChenMed and its members with respect to the pharmacy benefits.
Works with providers to ensure accurate coverage determination decisions.
Performs outreach to patients and providers as part of quality and/or cost control initiatives.
Performs other duties as assigned and modified at manager’s discretion.