Clinical Pharmacist (100% Remote)

  • Full Time
  • remote
Position Summary

This position works with Medical Directors, care managers, UM staff, contracted provider groups and other clinical and operational staff to support improving member outcomes, while managing drug costs associated with care being delivered to Health Options members. The Clinical Pharmacist performs functions supporting the management of the prescription drug benefit and maintaining regulatory compliance with the healthcare exchange marketplace, group products, NCQA/HEDIS, and disease management programs. These activities include, but are not limited to, formulary design and management, pharmacy and therapeutics activities including medication reviews, prior authorization activities, data analysis, quality improvement, drug utilization review, pharmacy cost containment strategies and programs, member and provider communications, and provider educational programs. Remote work is available based on operational needs and supervisor approval. Periodic in-office work is required.

Essential Functions And Responsibilities

  • Responsible for managing and operationalizing the process related to medical pharmacy benefits, including the development of new and updating existing policies related to clinical authorization criteria.
  • Serves as the clinical pharmacy expert on a variety of committees and workgroups (e.g., Quality Assurance, Medical Management, Clinical Code Review) and presents on various topics as necessary.
  • Primary owner of reviewing, maintaining, and ensuring configuration of drugs included in the USPTF preventive drug list and ensuring compliance with ACA, federal, state, and CMS requirements.
  • Performs Member and Provider outreach in support of pharmacy programs (e.g., ScriptSaver, medication synchronization, site of care infusion program).
  • Provides support to the quality initiatives of Health Options Star ratings, HEDIS, NCQA, and other quality measures to ensure the continued delivery of high- quality care and service.
  • Implements appropriate actions and educational programs to influence prescribers. Ensures systems are in place to monitor results.
  • Reviews member, physician, pharmacy, and drug utilization reports. Identifies trends affecting the pharmacy budget.
  • Coordinates / participates in Utilization Management (UM) and Care management activities related to improving outcomes for targeted disease management initiatives (e.g., COPD, Asthma, CHF, Diabetes).
  • Develops and maintains product documentation including training materials and necessary policies and procedures related to health plan based clinical pharmacy programs.
  • Facilitates process redesign, service improvement, cost reduction, and automation.
  • Assists and represents pharmacy services during government program, accreditation, and other regulatory audits as well as internal program audits.
  • Develops, implements, and coordinates new and existing member transitions relating to pharmacy benefit disruption including office administered injectables.
  • Develops and implements projects that enhance program clinical and cost effectiveness.
  • Provides direct functional support for the marketing and communication department to create member and provider materials.
  • Provides support to the business development, provider relations, product design departments regarding clinical activities related to sales, provider, and member acquisition/ retention (e.g., formulary development, provider education, employer/broker seminars).
  • Performs reviews of prior authorization requests and summarizes the approval and denial of such requests when necessary.
  • Conducts research into drug therapy related questions.
  • Promotes timely and effective communication based on individual and/or situational requirements and utilizes appropriate means to ensure adequate information flow.
  • Serves as primary preceptor for the APPE managed care rotation and assists in the education and mentoring of 4th year pharmacy students, and enhancing the current program while fostering the relationships with colleges of pharmacy.
  • Performs other duties as assigned.

JOB SPECIFIC KEY COMPETENCIES (KSAs)

  • Highly developed oral/written communication skills including the ability to effectively present information and respond to questions from groups including customers and the general public.
  • Must be self-motivated and capable of working independently with minimal supervision including the ability to be flexible and able to constantly review and reset priorities.
  • Must be able to handle multiple projects simultaneously.
  • Ability to appropriately identify emergency situations and follow through with the appropriate protocol.
  • Ability to maintain collaborative working relationships and to communicate effectively both verbally and in writing with health care professionals, other departments, network providers, state and federal regulatory and enforcement agencies, pharmaceutical manufacturers, and professional colleagues.

Skills and AbilitiesCommunicationAnalyticalOther Skills and AbilitiesDIVERSITY, EQUITY, AND INCLUSION STATEMENT

  • Working knowledge of health policy, sufficient to make decisions regarding Plan benefit structures and coverage issues.
  • Knowledge, skills, and abilities: Extensive knowledge of formulary development, drug use review, quality assurance, legal, regulatory, and standards of practice
  • Proficiency in using Microsoft Office Suite
  • Ability to research and analyze medical literature including drug information, disease states, and clinical practice guidelines.
  • Preferred: Previous experience with pharmacy claims processing or EHR systems
  • Preferred: Experience with audits (e.g., compliance, finance, PBM)
  • Capable of communicating (both verbally and in writing) with physicians, pharmacists, and other health care specialists as well as a broad range of non- health care professionals (including members).
  • Ability to write concise and clear reports, business correspondence, and procedure manuals.
  • Ability to read, analyze and interpret general pharmacy periodicals, clinical protocols, spreadsheets and governmental regulations.
  • Requires excellent attention to detail.
  • Previous managed care experience (e.g., health plan, PBM, ACO, integrated delivery network)
  • Working knowledge of managed care, population health principles, and policy development.
  • Experience implementing programs/decisions to impact HEDIS/NCQA results.
  • Make sound decisions and recommendations based on consideration of facts, priorities, resources, and alternatives.
  • Organize and manage time to accurately complete tasks within designated time frames in fast-paced environment.
  • Maintain current knowledge of and comply with regulatory and company policies & procedures.
  • Maintain confidentiality of patient and business information.
  • Flexibility to adjust work hours to meet business demands.

Benefits

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

  • Respectful, open communication and cooperation between all employees.
  • Teamwork and participation, encouraging the representation of all groups and employee perspectives.
  • Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
  • Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

QUALIFICATIONS AND CORE REQUIREMENTS

  • BS Pharmacy or PharmD degree from an accredited College of Pharmacy.
  • Active, unrestricted license to practice pharmacy in the State of Maine
  • Preferred: Minimum of 2 years of full-time experience as a clinical pharmacist with involvement in formulary development, drug use evaluation, and quality assurance activities.

To apply for this job please visit www.linkedin.com.

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