Job Description :
This job works in a team oriented environment monitoring FDA-approvals, drug manufacturer pipelines, and assess drug utilization reports, in order to develop and execute the the Organization's Drug Formulary,
and/or recommend codes for pharmaceutical based reporting. The incumbent may write drug monographs for Committee review; develops and implements the Organization's 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. If acting in the capacity as a clinical pharmacist the
incumbent may also review UM requests; provide consultation into the case and disease management identification process, and consult with the Organization's Associate Medical Directors and Medical
Directors when appropriate, follow-up on appeals in accordance with our regulatory guidelines. The incumbent develops and implements physician, pharmacy, account, and member educational initiatives that promote the Organization’s Formularies, utilization management programs, and case/ disease
management initiatives; providing clinical review and decisions for physician and member appeals and participates on cross-functional committees to develop and implement clinical and operational initiatives.
- Monitor FDA-approvals, drug manufacturer pipelines, assess drug utilization reports, and write drug monographs for Committee review to develop the Organization's 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.
- 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. 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.
- 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.
- Bachelor of Science in Pharmacy with experience in clinical / formulary management or a Doctor of Pharmacy degree with experience in clinical formulary management
- 5 years of related, progressive experience int he 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
- Be able to quickly identify and prioritize essential elements of problem
- Independently or in a team, 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
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
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 job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
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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, age, 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, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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