Job ID: J126341
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jun 25, 2018
I. GENERAL OVERVIEW:
The clinical pharmacist will work in a team oriented environment. The employee will monitor FDA-approvals, drug manufacturer pipelines, and assess drug utilization reports, in order to develop and execute the Highmark Drug Formulary, and/or recommend codes for pharmaceutical based reporting. The employee may write drug monographs for Committee review; develop and implement Highmark management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling, pharmacy policy review and development and/or review of member specific information to improve individual outcomes as an adjunct to health coaching. A clinical pharmacist may also review UM requests; provide consultation into the case and disease management identification process, and consult with Highmark Associate Medical Directors and Medical Directors when appropriate, follow-up on appeals in accordance with our regulatory guidelines. The employee will develop and implement physician, pharmacy, account, and member educational initiatives that promote Highmark’s Formularies, utilization management programs, and case/ disease management initiatives; provide clinical review and decisions for physician and member appeals and participate on cross-functional committees to develop and implement clinical and operational initiatives.
II. ESSENTIAL RESPONSIBILITIES:
1. Monitor FDA-approvals, drug manufacturer pipelines, assess drug utilization reports, and write drug monographs for Committee review to develop the Highmark Drug formulary and/OR provide recommendations for NDC code capture, and monthly identification of high risk members.
Gateway - Assist in the development of Gateway’s Drug Formularies by monitoring FDA-approvals and drug manufacturer pipelines, assessing drug utilization reports, and writing drug monographs for Pharmacy & Therapeutics Committee review.
2. Assist in the development and implementation of utilization management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling medical policy review and development, member facing outreach initiatives
3. Develop and implement physician, pharmacy, account, and member educational initiatives that promote Highmark’s Formularies, utilization management programs, and disease management initiatives.
4. Provide clinical review and decisions including but not limited to: physician and member appeals, member or provider information/education.
5. Participate on cross-functional committees to develop and implement clinical and operational initiatives within Integrated Clinical Services. May participate in outreach efforts as needed to effectively reach goals of Medication Therapy Management programs to include, but not limited to Comprehensive Medication Reviews and Targeted Medication Reviews.
6. Identify and assist in managing department process improvements to maximize overall efficiencies.
Manage individual projects for timely review with the Director, Clinical Pharmacy.
Participate in Medicare Stars performance measures to drive contribution to excellence (5 Stars).
7. Other duties as assigned or requested.
• Bachelor of Science in Pharmacy with experience in clinical / formulary management or a Doctor of Pharmacy degree with experience in clinical formulary management
• An understanding of managed care principles and practices is essential.
• Demonstration of strong verbal and written communication skills, as well as, proficiency in the use of computer-based data processing. Microsoft Office products, and database applications is required.
Knowledge, Skills and Abilities
A candidate should be able to quickly identify and prioritize essential elements of problem. Independently or in a team, a candidate should be able to identify the root issues and formulate potential solutions. It is imperative that the candidate accurately use logic and reasoning in identifying alternate solutions, conclusions or approaches to problems. Potential solutions should be synthesized into presentation, timetable to resolution and appropriate follow up with measurable outcomes.
Monograph and literature reviews to determine recommendations for formulary changes
Complete member case reviews for appropriate recommendations
Initiate and coordinate individual projects including determining timetables, metrics and monitoring for outcomes.
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