Medical Drug Policy and Programs Clinical Pharmacist - Hybrid

Blue Cross Blue Shield of Arizona•Phoenix, AZ

1d•Hybrid

About The Position

Blue Cross Blue Shield of Arizona (AZ Blue) is a Healthiest Employer award recipient, dedicated to inspiring health and making it easy for its members. AZ Blue provides various health insurance products and services to individuals, families, and businesses, along with tools for informed health decisions. The company operates with a hybrid workforce strategy called Workability, offering flexibility in work location. This specific position is classified as hybrid, requiring residency and work to be performed within the State of Arizona, with individual contributors expected to be onsite at least once per week. The purpose of this role is to manage the medical drug benefit for Medicaid beneficiaries. This involves implementing and managing the operations of the medical drug benefit, maintaining coverage criteria and policies for diverse Medicaid plans. The Clinical Pharmacist will assist health plan pharmacists by creating and updating clinical criteria consistent with regulatory requirements and evidence-based practice, reviewing medical drug benefit requests, and improving performance metrics related to medical drug authorization processes (e.g., turn-around times, decision integrity, system configurations, reporting). Additionally, the role includes educating staff on authorization systems, clinical coverage criteria, and case outcomes, as well as maintaining documentation for audit purposes. The position also involves completing projects assigned by Medical Services leadership and collaborating on medication use projects.

Requirements

5 years of practice experience with a health plan pharmacy service, managed care environment, and/or retail or hospital pharmacy service
2 years of practice experience in developing and applying clinical drug use criteria
Pharmacy degree from an accredited college of pharmacy
Active, current and unrestricted State of Arizona pharmacist license
Proficient in the principles and practices of managed care pharmacy
Broad based knowledge in a variety of pharmacy disciplines
Knowledge of Medicare and Medicaid regulations and guidelines regarding coverage determinations
Knowledge of peer-reviewed literature for production of PA Criteria Guidelines
Knowledge of drug options for the appropriate clinical management of member medical conditions
Ability to participate in Federal prescription programs
Ability to review drugs requests from a variety of medical disciplines
Ability to use electronic medical record and claims systems
Problem solving abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Work respectfully and positively with members
Ability to communicate effectively with physicians and other health care providers in situations involving high levels of conflict and disagreement
Ability to manage multiple projects and prioritize work tasks

Nice To Haves

Doctor of Pharmacy (Pharm.D) degree

Responsibilities

Maintain medical drug authorization system functionality to ensure appropriate application of clinical criteria and adherence to regulatory requirements of the medical drug authorization processes and outputs.
Establish medical drug reporting to demonstrate operational productivity, clinical decision outcomes and assessments, and compliance with regulatory requirements such as case turn-around times (TAT) and outreaches for information and decision notifications.
Implement, maintain, and enforce policies and procedures for member medical drug authorizations and service requests in accordance with accreditation, state and federal guidelines and requirements
Serve as clinical reviewer for requests for medical drug services, appeals, expert opinion requests, and complex member cases
Develop and maintain medical drug, and pharmacy drug use criteria and protocols in collaboration with health plan pharmacists
Support health plan pharmacists and VP of clinical operations or CMO regarding clinical coverage criteria and criteria committee activities and decisions.
Create and maintain site for access of Medicaid Business Segment medical drug coverage criteria
Assist with the provision of accurate Medicaid Business Segment medical drug and clinical criteria documents as well as notices to providers and members on medical drug coverage and clinical criteria changes.
Collaborate and communicate with interdepartmental staff and providers
Educate Medicaid Business Segment staff on medical drug authorizations systems, application of clinical criteria, and case outcomes as well as maintain appropriate documentation of systems and criteria for audit purposes.
Serve as a clinical resource and role model for Medicaid Business Segment medical drug and pharmacy staff and employees
Provide training to staff on medical drug authorization system operations as well as policies and procedures for member drug authorizations and service requests in accordance with accreditation, state and federal guidelines and requirements
Develop and implement member and provider education materials on clinical topics which include but are not limited to medical drug PA grid, utilization management criteria, and tools for effective access to covered medications.
Provide staff training on medication related topics that assists pharmacy staff in understanding the medication needs and concerns of our member.
Assist with the provision of activities associated with clinical programs that promote clinically appropriate and safe medication use:
Conduct clinical activities that satisfy and support regulatory requirements for safe and clinically appropriate medical drug services which includes but is not limited to member drug therapy reviews, provider drug prescribing or dispensing reviews, high-cost medication trend reviews, and medication reconciliations.
Oversee, conduct, and maintain medication therapy management activities that decrease over or under utilization of medications and improve member health through closing gaps in care and improving medication adherence.
Perform all other duties as assigned including but not limited to input of medical drug contracts, oversight of medical drug distributors and vendors, and medical drug claims issues