Clinical Pharmacist 1

Position Title: Clinical Pharmacist 1

Work Location: Remote

Assignment Duration: 3 Months

Work Schedule: 9am - 6pm EST No OT

Position Summary:

• Pharmacy Appeals Department - Dept 247
• Inclusive team culture, learning environment (not punitive)
• Pharmacy Ops Dept includes PA and Appeals - no key projects
• Evaluate redetermination and appeals coverage requests
• Department growth
• Increased volume

Typical Day in the Role

* Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician's recommended denial, suggested formulary alternatives, comments and attachments for appropriateness.

* Verifies member's ID number and date of birth.

* Verifies member's eligibility in the appropriate health plan eligibility system.

* Records carrier and group number if applicable.

* Checks for previous prior authorization decisions.

* Verifies coverage in member's prescription benefit when necessary.

* Verifies coverage in member's health plan benefit when necessary.

* Evaluates prescription claim history.

* Reviews chart notes and/or lab values.

* Identifies provider specialty when appropriate.

* Applies Medical Policy Criteria to prior authorization requests.

* Evaluates whether request meets criteria for approval.

* Reviews the request using professional clinical judgment on a case by case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.

* Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool

* Communicates with physicians regarding prior authorization:

o For a non-formulary drug

o Plan benefits, exclusions

o Quantity limits

o Age restrictions

o Formulary alternatives

* Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department)

* Compiles data for reporting purposes:

o Drug utilization of non-formulary drugs

o Overturned IPS recommended denials

o Audit pharmacy claims greater than $200.00

o Suggest addition or deletion of drugs to/from the formulary

o Updating qty/days or age limit ends

o Support National P&T Committee

o Other tasks which may arise during the performance of any of the above mentioned duties

Qualification & Experience:

Candidate Requirements

Education/Certification
Required: Pharm D.
Preferred: n/a

Licensure
Required: Any US state
Preferred: n/a

• Years of experience required
• Disqualifiers
• Best vs. average
• Performance indicators

Must haves: At least one year of professional RPh experience

Nice to haves: Some experience working in managed care, understanding of Medicare/Medicaid law

Disqualifiers: n/a

Performance indicators: * Sign 85 - 100 cases daily

• Top 3 must-have hard skills
• Level of experience with each
• Stack-ranked by importance
• Candidate Review & Selection

1
Self-Motivated/Good Time Management Skills

2
Working Knowledge of Office Suite

3
Goal Oriented