Clinical Pharmacist 1

Position Title: Clinical Pharmacist 1
Work Location: Remote
Assignment Duration: 3 Months - Possible extension
Work Schedule: 9am - 6pm EST No OT

Pharmacy Ops Dept includes PA and Appeals - Evaluate redetermination and appeals coverage requests

Typical Day in the 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 $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.

Qualification & Experience:

Candidate Requirements Education/Certification Required: Pharm D. Preferred: n/a Licensure Required: Any US state Preferred: n/a

• Years of experience required
• Disqualifiers
• Best vs. average
• Performance indicators

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 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
• Level of experience with each
• Stack-ranked by importance
• Candidate Review & Selection

1 Self-Motivated/Good Time Management Skills 2 Working Knowledge of Office Suite 3 Goal Oriented