Clinical Pharmacist - Managed Care

The Clinical Pharmacist will be responsible for the daily Clinical Pharmacist operations and decision-making process related to Part D Coverage Determinations. The Clinical Pharmacists will also be responsible for all aspects of Formulary maintenance and management. The Clinical Pharmacist may also be required to meet with prescribers on a one-on-one basis to promote cost-effective prescribing initiatives and strategies and will assist in the identification of cost-saving opportunities and outliers, the development of educational material, the evaluation of prescriber utilization data, and the deployment of cost reduction strategies.

The Clinical Pharmacist will assist in the development, administration and management of the Health Plan’s Medicare Prescription Drug Program, including compliance and oversight of Medicare Part D laws, regulations and reporting requirements, benefit configuration and benefit transition process, and drug reviews for Pharmacy & Therapeutics Committee Meeting.

The Clinical Pharmacist will assist in the development and oversight of the Part D Drug Formulary and administration of the Drug Utilization Management Program. This includes weekly new drug reviews and coding to be submitted to the Pharmacy Benefit Manager, New Contract Year formulary evaluation, and rebate strategy evaluation.

The Clinical Pharmacist may review and present New Drug Entities, New Generics, and Line Extensions at the Plan’s Pharmacy & Therapeutics Committee Meeting.

This position will work with other constituents, including but not limited to:
Pharmacy Director, Chief Medical Officer, Medical Director, Pharmacy team, Member Services, Utilization Management, IT/Analytics, Finance, Case Management, Provider Relations, Compliance, Sales/Marketing and the PBM account team.

• Formulary Management and FRF submissions in HPMS
• Drug Monographs for New Drug Entity Reviews
• Development of Education Material for Providers
• Member Medication Reviews for identification of Polypharmacy, Inappropriate prescribing
• PBM Rebate Strategy implementation and oversight
• Pharmacy & Therapeutics Committee Meeting
• CMS Model Letter Reviews
• Coverage Determinations and monitoring of optimal cost effective drug management
• Perform medical necessity reviews for formulary exceptions and prior authorizations according to the Medicare Part D defined guidelines
• Work with the Pharmacy Benefit Manager (PBM) and formulary manager to manage formulary changes and update the Plan’s website to reflect the most up to date approved CMS versions of the formulary
• Assist providers with recommendations in an effort to promote cost-effective alternatives.
• Guide pharmacy technicians with clinical questions from prescribers, pharmacies, and/or members
• Ensure clinical alignment of drug management across medical and pharmacy benefits, including identification of new opportunities for drug management, safety programs, and medical/pharmacy cost savings
• Make recommendations on utilization management edits such as Prior Authorization, Step Therapy and Quantity Limits
• Provide internal professional staff education regarding the pharmacy benefit and formulary
• Assist with the development and implementation of the Pharmacy Department’s Policies and Procedures
• Responsible for pharmacy oversight of member communications including correspondence associated with coverage determination decisions
• Review prescription utilization data to identify outliers and trends, including high-cost drug category drivers
• Develop and implement cost-saving strategies for prescription drugs
• Evaluate medication regimens for members with polypharmacy and assist with medication reconciliation
• Develop educational material for prescribers to communicate pharmacy cost-management…