Clinical - Clinical Pharmacist 1 - 210392

Title: Clinical Pharmacist

Location: Fully Remote

Duration: 3months

Schedule: 1 st (9am to 6pm EST) No OT

XXXX: XXXXXXXXXXX0 to XXXXXXXXXXX7 an hour

Description :

Typical day in a 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:
• 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 XXXXXXXXXXX
• 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.

Education/Certification Required: Pharm D.

Licensure Required : Any US state

Ideal candidates are:

• Self-motivated
• Metric driven (retail experience can be an indicator of this but not always)
• What are the metric goals in their current role? How many cases per day do they complete?
• This is crucial information if they are working in a prior auth role or have worked prior auth before
• Easily adaptable to frequent change
• Any previous client experience or experience with our systems (MHK, ESI, 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 skills:

• Self-Motivated/Good Time Management Skills
• Working Knowledge of Office Suite
• Goal Oriented