Clinical Pharmacist

• Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria.
• Report to utilization review statistics to corporate compliance committees.
• Review data and summarize daily utilization review numbers.
• Responsible for tracking compliance of review cases.
• Provide clinical guidance and support to the assigned pharmacy technicians.
• Knowledge of drug coding (NDC, GCN, GPI and USC) and NCPDP claims adjudication systems.
• Review guideline criteria for prior authorization and non-formulary drugs in support of Pharmacy and Therapeutics Committee function and pharmacy benefit design.
• Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practices.
• Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews.
• Engage Medicare members, pharmacies, and providers to close adherence and SUPD (Statin Use in Persons with Diabetes) gaps. Complete Comprehensive Medication Reviews (CMRs) with Medicare members.
• Make outreach to Medicare members to assist in removing barriers to medication adherence.
• Partner with pharmacies and providers to close adherence gaps when the Medicare member is unengaged or when the Medicare member requires assistance.
• Contact providers to close SUPD (Statin Use in Persons with Diabetes) gaps.
• Complete Comprehensive Medication Reviews (CMRs) with eligible Medicare members to give the member a better understanding of their medications and health.
• Send interventions to providers through fax or the CMR platform to alert the provider of potential drug interactions and adverse reactions, dose changes, adherence issues, etc.
• Provide counseling to Medicare members regarding medications.
• Provide Medicare members with information regarding their pharmacy benefits (ie. formulary, preferred pharmacy, supplemental benefits, etc.).
• Provide clinical guidance and support to the Pharmacy Quality Specialists.

• Bachelor's degree or advanced degree.
• 3+ years of experience in related field.
• NC state pharmacy license and residence.

• Able to work on computers and has work from home experience.
• High volume call.

• Medicare and Medicaid experience.
• Health Plan.
• Managed care experience.
• MTM/CMR

• 3-5

• Pharmacist license for the state.
• Pharm D is preferred.

• Retail, HMO, DSNIP

• Participating in comprehensive medication review.
• Cold calling members and reaching out on non adherence.
• Advocate for member on adherence gaps.
• Time that you will be on the phone is going to be 3.5 to 4.5 hours a day

• Do you have any familiarity with Medicare STARs and metrics? If so, please explain.

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At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.