Medical Drug Policy and Programs Clinical Pharmacist - Hybrid

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses, as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite, or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements; however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona. Purpose of the Job Manages the medical drug benefit for Medicaid beneficiaries by implementing and managing the operations of the medical drug benefit and maintaining the medical drug coverage criteria and policies for the diverse Medicaid plans. Assists health plan pharmacists by creating and updating clinical criteria for medical drug coverage consistent with regulatory requirements and evidence based clinical practice, reviews requests for medical drug benefit services, and works to improve performance metrics associated with the medical drug authorization processes which include but is not limited to medical authorization case turn‑around times, case decision integrity, operations best practices, efficient system configurations, and actionable reporting. Educates appropriate staff on medical drug authorization systems, application of clinical coverage criteria, and case outcomes as well as maintains appropriate documentation of systems and criteria for audit purposes. Completes projects assigned by Medical Services leadership and works with other health plan pharmacists on medical and pharmacy medication use projects as requested. Qualifications Required Qualifications Required Work Experience 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 Required Education Pharmacy degree from an accredited college of pharmacy Required Licenses Active, current and unrestricted State of Arizona pharmacist license Preferred Qualifications Preferred Education Doctor of Pharmacy (Pharm.D) degree Essential Job Functions and 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 and outreach 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 members. 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 include but are 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. The position requires a full‑time work schedule. Full‑time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Competencies Required Competencies Required Job Skills 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. Required Professional Competencies Problem solving abilities. Work cooperatively, positively, and collaboratively in an interdisciplinary team. Work respectfully and positively with members. Ability to manage multiple projects and prioritize work tasks. Our Commitment AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group. #J-18808-Ljbffr Blue Cross Blue Shield of Arizona