Clinical Specialist II

Pharmpix-posted about 14 hours ago

Full-time • Mid Level

Onsite

101-250 employees

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This position reports to the Clinical Supervisor – Pharmacy Coverage Determinations. The Clinical Specialist II – 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 II – Pharmacy Coverage Determinations s 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 II – Pharmacy Coverage Determinations requires strong attention to detail, empathy, and professionalism in every interaction, and a strong commitment to professional physician interactions. ESSENTIALS ROLES AND RESPONSIBILITIES This position requires a career ladder progression from the Clinical Specialist I position. The successful Clinical Specialist II – Pharmacy Coverage Determinations will demonstrate all job-related functions associated with a Clinical Specialist I – Pharmacy Coverage Determinations in addition to the following requirements:

Review, analyze, and validate data files and supporting documentation to ensure accuracy before submission of data to external or internal customers.
Research and report trends to management and participate in additional analysis to recommend changes/corrections to processes.
Organize, execute, and deliver to management monthly reports if requested by the Clinical Manager or Clinical Director.
Draft schedules and daily work plans for the Clinical Specialists.
Provide supervision of and feedback for Clinical Specialists I.
Track quality results and statistics in a systematic and measurable format. Provide analysis of errors to management, at regular intervals, outlining and summarizing any issues. Provide recommended enhancements, procedure changes, and training format to prevent future errors.
Research, test, and respond to inquiries regarding the system's capabilities.
Participate and represent the department in cross-functional meetings for external audit as needed.
Assist with business requirements and testing.
Assist with updates to policies and procedures due to process and/or changes based on regulatory guidance, e.g. Centers for Medicare & Medicaid Services (CMS) guidance, and/or Client direction.
Create training documentation and provide internal training as needed.
Serve as a mentor and case reviewer for all new employees on a probationary or training period.
Train and mentor staff to build pharmacy benefit management industry knowledge and to provide knowledge transfer necessary for system use to meet client-specific requests. Provide department system orientation to new hires.
Provide feedback to the Clinical Manager and Clinical Director regarding the processing of PA cases referred for clinical review and provides in-service education to management regarding topics such as PA guidelines and diagnoses commonly seen as part of the PA review process.
Create staff in-services and presentations for team learning and case reviews.
Provide after-hours (on-call) pharmacy technician services, if necessary.

Two to three years as a Clinical Specialist I with exemplary work performance, attendance, and review record.
Performance and benchmark metrics are met consistently.
Completion of cross-training in at least one other Clinical area: Formulary or Clinical Programs.
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.
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.
A demonstrated ability to establish and maintain quality control standards.
Ability to accurately read and interpret physicians’ prescription orders, medical charts, and diagnostic test and laboratory results.
Ability to calculate figures, rates, ratios, percentages, and amounts in all units of measure using whole numbers, fractions, and decimals.
Ability to develop and maintain productive relationships with other internal departments, PharmPix clients, and other health care professionals.
Ability to learn and convey medical and formulary technical information at the level of the client, member, or healthcare professional.
Ability to follow guidelines for accurate member interventions while meeting or exceeding performance standards.
Ability to organize and integrate organizational priorities and deadlines.
Ability to prioritize, check for errors, and spot inaccuracies.
Ability to see trends in utilization patterns.
Ability to solve practical problems and deal with a variety of standards effectively using good problem solving and analytical skills.
Ability to understand the importance of and maintain the confidentiality of all patient information.
The physical demands described here represent those that must be met by an employee to perform the essential functions of this job successfully. While performing this job's duties, the employee is regularly required to talk or hear, sit, stand, and walk.
The position requires that up to 25 pounds of weight be lifted.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines.
May require evening or weekend work.

Fully bilingual English and Spanish (preferred).

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