Clinical Quality Pharmacist

Job ID: J125719
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jun 21, 2018

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Description

JOB SUMMARY

This job will assist with the strategy, program development and collaboration of the Gateway departments working on HEDIS pharmacy gap closure, as well as, performance management for external vendors assisting with these efforts.  The incumbent educates teams and monitors key controls in keeping track of CMS requirements and educating stakeholders regarding pharmacy quality measures. The incumbent will also participate in program implementation and provider performance management which is tracked by provider metrics, inclusive minimally of 4 STAR gap closure, Part D measures, Medicaid Pay for Performance measures and improved quality.  Works with other departments in pharmacy, as well as, quality and compliance to identify performance improvement opportunities through analysis and discussion. 

ESSENTIAL RESPONSIBILITIES

  • Monitor FDA-approvals, drug manufacturer pipelines,   assess drug utilization reports, and write drug monographs for   Committee review to develop the Organization Drug formulary and/OR provide recommendations for NDC code capture, and monthly identification of high risk members.  
  • 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.
  • 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
  • Develop and implement physician, pharmacy, account, and member educational initiatives that promote the Organization’s Formularies, utilization management programs, and disease management initiatives.
  • Provide clinical review and decisions including but not limited to:  physician and member appeals, member or provider information/education.  
  • Participate on cross-functional committees to develop and implement clinical and operational initiatives within Integrated Clinical Services.  
  • 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.
  • 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).
  • Other duties as assigned or requested.


QUALIFICATIONS

Minimum

  • Bachelor of Science in Pharmacy with experience in clinical / formulary management or a Doctor of Pharmacy degree with experience in clinical formulary management
  • 3-5 years of related, progressive clinical experience in the area of specialization.
  • 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

Preferred

  • One year experience with Medicaid Pay for Performance Measures
  • One year experience with Medicare Part D STARs Measures
     

Skills

  • Ability to quickly identify and prioritize essential elements of problem
  • Independently or in a team, should be able to identify the root issues and formulate potential solutions
  • 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

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees?

No

WORK ENVIRONMENT

Is Travel Required?

No

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
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For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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