Clinical Operations Pharmacist (44572)

Overview The Clinical Operations Pharmacist works in conjunction with the Clinical Program Pharmacist and Medical Management teams to review medication utilization and develop/implement initiatives to ensure appropriate drug therapy prior authorization decisions are consistent with covered benefits, quality of care, and medical necessity. Work is focused at both the individual patient and population-based therapy level. He/she supports the department by coordinating the activities of the Senior Manager of Regulatory and Pharmacy Operations and formulary advisory committees. He/she may also participate in care management activities and provide backup coverage to the Senior Manager as needed. Duties and Responsibilities Responsibilities include, but are not limited to the following: Responsible for the pharmacy utilization management (UM) reviews. Uses clinical expertise and independent judgment to evaluate prior authorization (PA) to determine if requests meet established PA criteria, clinical medical policies, or clinical medical necessity (CMN) criteria. Maintain and support pharmacy UM programs and provide implementation support for formulary management decisions and clinical policies. Assist with the creation and maintenance of administrative and utilization management policies. Support medical cost savings strategy including, but not limited to, executing UM reviews for high-cost medications and evaluating whether complex treatment plans are medically appropriate. Make clinical UM recommendations for leadership level review. Engage ordering providers in discussions related to CMN. Document all aspects of the PA review process within PA software applications per NCQA standards. Provide pharmacy-related customer service to external and internal parties. Serve as drug information resource for internal departments (e.g., Care Management, Medical Directors, Grievance and Appeals Unit). Provide ongoing leadership and support to Pharmacy Technicians to ensure day-to-day service and production goals are met. Provide peer trainings and assist with onboarding of new employees. Maintain current knowledge of and ensure compliance with government and federal regulations. Commit to regulatory adherence to meet turnaround time requirements set by State and Federal regulators. Evaluate quality controls. Audit cases to ensure compliance with regulatory requirements and to evaluate quality improvement opportunities. Follows best practices to maintain high production and quality standards to deliver excellent provider, member, and employee experience. Continuously look for ways to streamline and improve operational workflows. Demonstrate effective planning, organizational, and decision-making skills; ability to handle multiple high-priority projects with competing deadlines. Support the documentation of processes required for day-to-day operations. Demonstrate a strong understanding of all lines of business (LOB) including benefit design and regulatory requirements per LOB. Performs other duties as assigned, including but not limited to: Oversight of daily operational duties and work with senior leadership to de-escalate issues Support departmental projects when assigned Maintain daily, weekly, monthly, quarterly and annual operational metrics to ensure optimal and comprehensive operational efficiency and accuracy. Analyze, report, trend, solution and escalate findings from routine reports and provide education to pharmacist staff on opportunities. Engage with pharmacy department vendors on operational items to ensure appropriate escalation and resolution. Qualifications Required: Registered Pharmacist - active, unrestricted license in the state of Rhode Island (Consideration will be given to individuals without current RI license. Must provide documentation confirming RI Pharmacist application within 24 hours of offer) Bachelor's Degree in related field and/or PharmD Minimum of one (1) year experience working as a Pharmacist Strong analytical skills Strong clinical skills Ability to resolve issues and complete required duties with little supervision Good verbal and written communication skills including presentation skills Intermediate to Advanced skills in Microsoft Office (Word, Excel, Outlook) Flexibility in work schedule. Ability to work evenings and weekends Preferred: Experience working in a managed care setting, either from the provider, the payer, or the PBM side of the industry Managed care residency Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status #J-18808-Ljbffr Neighborhood Health Plan of Rhode Island