Job Details
Description :
The Clinical Pharmacist is an integral part of the client's pharmacy management team and will work to drive pharmacy initiatives and clinical programs within the Medi-Cal, Medi-Cal Whole-Child Model, Medicare and Program for All-Inclusive Care for the Elderly (PACE) lines of business. The incumbent will research, develop, update drug utilization management strategies and work to promote clinically appropriate prescribing practices, which adhere to client's formulary, regulatory guidelines and national clinical practice guidelines. The incumbent will interact frequently and independently with plan members, prescribers, pharmacies, collaborative care team members and with the Pharmacy Benefit Manager (PBM). General duties will include participation in clinical programs, development of drug utilization criteria, review of prior authorizations and appeals and interface with plan members and prescribers to discuss drug therapy.
Responsibilities :
- 95% Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Generates and analyzes claims and utilization reports to track general trends in drug utilization and to identify potential targeted utilization management activities. Develops and updates drug utilization criteria. Proactively develops and maintains contacts and relationships with providers key to successful interaction and intervention activities. Participates in medication review, disease state management, and other clinical quality improvement programs such as Medication Therapy Management (MTM), Transitions of Care (TOC), interdisciplinary care teams and PACE.
- Assists the Pharmacy Director and the Manager of Clinical Pharmacists in the preparation of drug monographs and utilization reports for the Pharmacy and Therapeutics committee. Utilizes clinical and regulatory guidelines in the review of drug prior authorization and appeals requests. Adheres to regulatory compliance and quality guidelines as well as The Client's Health's policies and procedures. Updates The Client's Health's pharmacy policies and develops new policies and procedures when needed. Works with management to recommend, develop and implement target drug utilization intervention programs and other Drug Utilization Review/Drug Utilization Evaluation (DUR/DUE) activities. Works with the Manager of Clinical Pharmacists and within Medical Management (e.g., with data manager, case managers, etc.) on various data integration and disease management and outcomes projects. Reviews members' medication profiles and makes recommendations to health care providers based on evidence-based medicine and national guidelines for disease management as part of the The Client's polypharmacy program. Serves as the plan representative for state fair hearings. Resolves complaints, grievances and appeals.
- 5% - Other
- Completes other duties and projects as assigned.
Minimum Qualifications :
- Doctor of Pharmacy degree is required.
- Current knowledge and expertise in clinical pharmacology and disease states is required.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying
Preferred Qualifications :
- Experience in pharmacy practice or residency in pharmacy practice.
- Centers for Medicare & Medicaid Services (CMS), Department of Managed Health Care (DMHC), and/or National Committee for Quality Assurance (NCQA) audit experience.
- Bilingual in English and in one of The Client's Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese).
Required Licensure / Certifications :
- A current, valid, unrestricted California State registered Pharmacist license is required.
Knowledge & Abilities :
- Develop rapport and establish and maintain effective working relationships with The Client's Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events. Organize, be analytical, problem-solve and possess project management skills.
- Work in a fast-paced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration. Motivate and lead multi-program teams and external committees/coalitions.
- Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.