Clinical Pharmacist 1

Job Profile Summary

Location: 100 % Remote Shift: 9am – 6pm EST, No OT Duration: 3 months

Job Profile Summary

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.

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: for a non-formulary drug, plan benefits, exclusions, quantity limits, age restrictions, formulary alternatives.

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

Compiles data for reporting purposes: drug utilization of non-formulary drugs, overturned IPS recommended denials, audit pharmacy claims greater than $200.00, suggest addition or deletion of drugs to/from the formulary, updating qty/days or age limit ends, support National P&T Committee, other tasks which may arise during the performance of any of the above mentioned duties.

Candidate Requirements

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

Licensure - Required: Any US state - Preferred: n/a

Years of experience requiredDisqualifiersBest vs. averagePerformance indicators - Ideal candidates are: Self-motivated, Metric driven (retail experience can be an indicator of this but not always), easily adaptable to frequent change, any previous client experience or experience with our systems (MHK, Client, Micromedex, AHFS to name a few), minimal gaps in employment history, licensure in the following states COULD be a plus – NC, IN, WA, NH, GA.

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 skillsLevel of experience with eachStack-ranked by importanceCandidate Review & Selection - 1 - Self-Motivated/Good Time Management Skills

2 - Working Knowledge of Office Suite

3 - Goal Oriented