Supervisor Health Plan Clinical Pharmacist - Kelsey Seybold Clinic - Pearland Admin Office

UnitedHealth Group•Pearland, TX

About The Position

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together. Under the supervision of the Part D Pharmacy Manager - Health Plan Services, this position is primarily responsible for performing and/or supervising pharmacist activities related to all Pharmacy Quality Initiatives (i.e. RxQI, MTMP, CPAS, Adherence, Hospital Discharge Prgm, Fraud Waste and Abuse monitoring, Part D coverage determination and appeals processing) for Kelsey-Seybold Clinic and/or KelseyCare Advantage. This position will oversee program staff as well as monitor and report ongoing progress of pharmacy quality initiatives. This position will also perform operational maintenance and/or implementation of new clinical services as well as any additional duties deemed necessary for the Pharmacy Services Department.

Requirements

Pharm D. degree
Current and active Pharmacy License
TSBP Registered Pharmacist
Customer Service experience
Proficient with computer applications that include, but are not limited to: Microsoft Word, Excel, and Access
Demonstrated ability to lead others on team
Demonstrated ability to communicate with all levels of the Management
Proven detail oriented with good verbal and written communication skills, interpersonal skills, professional appearance, and ability to work effectively in a fast-paced work environment
Proven excellent organizational skills
Proven high stress tolerance
Proven good alpha/numeric data entry skills with minimal errors
Demonstrated solid multitasking, problem solving & analytical skills

Nice To Haves

Completion of a Managed Care Pharmacy Residency Program or Pharmacy Practice Residency Program (PGY1)
ASHP Immunization Certification
BLS CPR Certification
3+ years of Medicare Part D experience
Experience with prior authorization, coverage determination and appeals processing
Customer Service experience
Auditing experience
Supervisory or management experience
Experience with vendor relations
Knowledge of the Pharmacy Benefit Management (PBM) industry
Knowledge of Medicare 5-star ratings and HEDIS measures

Responsibilities

Answer inbound calls and conduct outbound calls regarding processing of coverage determinations.
Review medical information essential for coverage determination to be conducted.
Properly enters data into software program(s).
Enter overrides in appropriate systems to process payment.
Generates letters and/or reports.
Works all appropriate program workflow steps and queues as assigned. After hours/weekend coverage as assigned
Responsible for conducting clinical pharmacy services through Pharmacy Quality Initiative Programs. During these encounters with members the following will be conducted: review of all current medications, review pharmacy claims in contracted PBM systems, drug-drug interactions screened, therapeutic alternatives recognized, communication with physician regarding drug therapy, patient counseling, medication reconciliation within EPIC (medical chart) and follow-up with member
Lead program training and oversight.
Provide training and supervise program staff, pharmacy residents and assigned interns.
Perform ongoing and annual program/employee evaluations and corrective actions.
Schedule Health Plan Pharmacy Services Department personnel to ensure program productivity.
Monitor daily duties and program work queues to ensure program requirements and department goals are achieved.
Create program reports weekly, monthly, quarterly, annually or upon request from management.
Communicate program and staff concerns to management and staff
Assists in the development of clinical pharmacy program enhancement and better practices within the department including but not limited to RX Quality Initiative (RXQI), Pharmacy Quality Initiative Programs (QIP), Adherence Programs, Medication Therapy Management Program (MTMP), Centralized Pharmacy Anticoagulation Service (CPAS), Hospital Discharge Program (HDP), Fraud Waste and Abuse (FWA) protocols, and Coverage Determination (CD) processes
Communicate with physicians and other healthcare personnel to discuss specific medication recommendations, therapies for cost-effective care, general drug information, and educate about health plan prescription drug benefits
Communicates instructions to internal and external individuals and/or departments. Furnishes and obtains information from other entities/vendors
Monitors and evaluated claims for appropriate use by members, physicians and pharmacies. Conducts drug utilization review of potentially fraudulent claims, abuse, and/or waste.
Assists in reviewing claims adjudicated by the PBM to ensure payment for formulary products are processed correctly. Perform audits. Reports risks to management
Coordinates, monitors and/or develops reports required by CMS to ensure accuracy and timely submission, in addition to responding to any CMS inquires made concerning Part D. Monitors Part D Performance Reports
Provides clerical support for Part D duties and audits. Provides administrative and clinical support for special projects. Responsibilities include attending and scheduling meetings, calendar management, dictation, answering phones and routine questions
Ensures prompt and courteous customer service by all Health Plan Pharmacy Services personnel.
Responsible for compliance to federal and state Pharmacy laws.
Triages patient emergencies and provides the appropriate follow up as needed.
Attends meetings as designated and completes any other duties deemed necessary to support Pharmacy Health Plan Services activities.
Responsible for adherence to federal and state Pharmacy laws

Benefits

In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

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