CLINICAL SPECIALIST I

TPIS•Guaynabo, PR

About The Position

This position reports to the Clinical Supervisor - Pharmacy Coverage Determinations. The Clinical Specialist I – Pharmacy Coverage Determinations is responsible for reviewing, evaluating, communicating, documenting, tracking, and making determinations within the protocol for pharmacy benefit coverage determination requests such as requests for formulary exceptions, prior authorization (PA), step therapy (ST), and quantity limit (QL) exceptions, and override processes for delegated utilization management (UM) products and services based upon regulation and defined procedures. The Clinical Specialist I – Pharmacy Coverage Determinations will review and evaluate coverage determination requests for the clinical opportunity to address the appropriateness of therapy, clinical interventions, generic substitution, or therapeutic interchange opportunities with potential cost savings outcomes, and/or interventions. This individual will focus on initiating, supporting, and continuing cost-effective, rational drug, and disease therapy, utilizing distinct but inter-related clinical management and cross-departmental functions that focus on improving the health of members while reducing overall health care costs. They will be responsible for providing clinical support services to plan sponsors contracting for clinical services. They will review medication request guidelines for clinical appropriateness and operational efficiency through knowledge of the practice of pharmacy, including laws, rules, and regulations of the various US states, the usual methods of filling prescriptions, and common habits of the profession. The Clinical Specialist I – Pharmacy Coverage Determinations requires strong attention to detail, empathy, and professionalism in every interaction, and a strong commitment to professional physician interactions. This position allows for a career ladder progression with the levels of Clinical Specialist II and Clinical Specialist III positions.

Requirements

High-school diploma
Pharmacy Technician Associate Degree from an accredited institution (where mandated by law)
Nationally Certified Pharmacy Technician (CPhT) required.
Current, valid, and unrestricted state or Puerto Rico Pharmacy Technician license/registry certificate.
1 – 2 years clinical experience in a health care environment or at a pharmacy benefit manager.
Open to newly licensed technicians.
General knowledge of pharmacology for major drug categories.
Knowledge of Microsoft Access, Word, Excel, PowerPoint, and Outlook, as well as Internet Explorer.
Knowledge of pharmaceutical products, drug names (brand/generics), dosage forms, and pharmacy terminology.
Knowledge of Retail Pharmacy Operations and an understanding of insurance billing, third-party systems, point of sale, online pharmacy claims processing system experience preferred.
Knowledge of the purpose, organization, and policies of community health care delivery and pharmacy regulations/regulatory agencies.
Excellent phone, written, listening, and follow-through skills.
Skill in exercising a high degree of initiative, judgment, discretion, and decision-making to achieve organizational objectives.
Skill in exercising judgment in applying, interpreting, and coordinating departmental policies and procedures.
Strong analytical, customer service, problem analysis, decision-making, and verbal and written communications skills.
Time Management Skills: Skill in establishing priorities and accomplishing tasks promptly.

Nice To Haves

Fully bilingual English and Spanish (preferred).

Responsibilities

Responsible for the accurate and timely review, disposition, documentation, and system input at the drug-specific level of submitted prescription UM requests. Accountable for processing PA requests according to the urgency of the medication or the member’s health condition to avoid member disruptions following state, federal, and Medicare Part D standards with an understanding of Medicare Coverage under Part D versus B and Appeal cases.
Process and time stamp all PA requests daily from fax or other means. Monitor incoming faxes and uploads all documents to the corresponding patient’s profile. Monitor the BaCMan Alert Application to ensure proper management of pharmacy benefit coverage determination requests. Change the Alert status to In Process when a prescription and/or justification is received by fax.
Responsible for faxing PA forms to providers, physicians, and members upon request. Responsible for assisting in faxing or calling prescriber and/or patients for various prescription clarification and UM-related questions.
Conduct an in-depth review of patient histories, medical records, using professional judgment to determine medical necessity and appropriateness. Obtain additional/missing information from the appropriate source via verbal or written communication, if necessary, to process PA requests. Document all contact/attempts to contact and information needed to complete a case. Initiate and continue direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
Utilize protocols, appropriate regulations, online clinical literature databases, and designated criteria along with clinical and medical knowledge, pharmaceutical knowledge of dosage forms and drug delivery systems, and utilization review to provide drug information support and research. Provide clinical literature documentation to support PA decisions as indicated by conducting a systematic procedure for performing a comprehensive literature search, and drawing appropriate conclusions based on a summary of a comprehensive literature search.
Appropriately document and record all PA activities following departmental, regulatory, and legal standards and within the patient profile. Change the Alert status to Approved or Conditional Denial after completing the coverage determinations evaluation. Maintain an efficient, organized, and orderly tracking and recording system for PAs and clinical program files and ensure accurate case classification and coding using diagnosis and ICD-9/10 codes. Respond to all requests via timely and accurate written communication to the member’s physician, the member, and the pharmacy that detail the outcome of the request.
Maintain appropriate system knowledge, including a comprehensive understanding of override processes and edits required to process a claim following policies and procedures.
Responsible for creating approval and denial letters to patients and providers based upon standardized letters based upon the appropriate PA, length of therapy, and/or reasons for denial. Completed letters are then sent for quality assurance validation before compilation and sending.
Refer cases not meeting criteria, protocols, or guidelines to pharmacist or physician review. Escalate requests to pharmacists when a request, question, or case requires extensive clinical review or denial. Understand when to escalate cases and to a pharmacist to interpret or provide direction on the case or question.
Responsible for handling pharmacy and physician calls related to the coverage determination review process or protocols. Receive inbound calls and requests from prescribers and initiates outbound calls to providers (physicians and pharmacies) and members to communicate case dispositions. Address escalated calls and non-standard customer service-related issues.
Respond in a timely, concise, professional, accurate, and detailed manner to inquiries in writing to Clients and Plan Sponsors who submit inquiries or cases to the Manage Engine Service desk or other means of communication.
Determine the presence of any medication therapy problems in a patient's current medication therapy and identify the appropriate action. Support improved member outcomes by identifying opportunities for member education and Pharmacist intervention through the clinical intervention program opportunities. Collect and organize all patient-specific information needed by the pharmacist to prevent, detect, and resolve medication-related problems and to make appropriate evidence-based, patient-centered medication therapy recommendations.
Meet or exceed departmental performance requirements consistently.
Assist in the development and implementation of goals, objectives, plans, and policies to achieve selected clinical program service outcomes as established by the Clinical Director and Pharmacists.
Carry out quality control measures and quality assurance programs for clinical services.
Actively participate in assigned interdepartmental workgroups and committees.
Effectively communicate with all levels of departmental staff, as well as members, clients, and healthcare professionals.
Maintain an awareness of developments in the community and pharmaceutical fields that relate to job responsibilities and integrate them into practice.
Understand the PBM mission, vision, values, and culture. Support clinical and corporate initiatives.
Take appropriate actions, assesses each situation, and follow through with the utmost attention to accurate communication.
Work in conjunction with other members of the clinical staff to audit and resolve issues that occur during daily operations.