Clinical Pharmacist - Managed Care

Doctors HealthCare Plans, Inc.; Coral Gables (FL); On-site; USD 110,000 - 135,000; Full time

Job summary

Doctors HealthCare Plans, Inc. is seeking a Clinical Pharmacist to oversee Part D coverage determinations and formulary management, coordinating with PBMs and plan stakeholders.

The role includes evaluating prescriber utilization data, identifying cost-saving opportunities, and developing educational materials for providers to promote cost-effective prescribing. Responsibilities also cover CMS compliance, drug reviews for the Pharmacy & Therapeutics Committee, and aligning drug management across

Qualifications

• Managed Care experience preferred but not required.
• Part D Coverage Determinations and Formulary Management experience preferred.
• HPMS FRF submission experience preferred but not required.
• Strong computer skills and ability to work with data and reporting tools.
• Florida license as Pharmacist with clinical background.

Responsibilities

• Formulary management and FRF submissions in HPMS.
• Develop education material for providers.
• Conduct member medication reviews to identify polypharmacy and inappropriate prescribing.
• Oversee PBM rebate strategy and cost-saving initiatives.
• Participate in Pharmacy & Therapeutics Committee meetings.
• Review CMS model letters and coverage determinations.
• Monitor optimal cost-effective drug management and prior authorizations.
• Provide internal staff education on pharmacy benefit and formulary.

Skills

Managed care experience

Cost-management

Strong communication

Detail-oriented

Education

PharmD degree

Florida pharmacist license

Residency PGY1 in managed care pharmacy

RPh with clinical experience

Tools

Microsoft Office

Programming or reporting software

Job description

The Clinical Pharmacist will be responsible for the daily Clinical Pharmacist operations and decision-making process related to Part D Coverage Determinations. The Clinical Pharmacists will also be responsible for all aspects of Formulary maintenance and management. The Clinical Pharmacist may also be required to meet with prescribers on a one-on-one basis to promote cost-effective prescribing initiatives and strategies and will assist in the identification of cost-saving opportunities and outliers, the development of educational material, the evaluation of prescriber utilization data, and the deployment of cost reduction strategies.

The Clinical Pharmacist will assist in the development, administration and management of the Health Plan’s Medicare Prescription Drug Program, including compliance and oversight of Medicare Part D laws, regulations and reporting requirements, benefit configuration and benefit transition process, and drug reviews for Pharmacy & Therapeutics Committee Meeting.

The Clinical Pharmacist will assist in the development and oversight of the Part D Drug Formulary and administration of the Drug Utilization Management Program. This includes weekly new drug reviews and coding to be submitted to the Pharmacy Benefit Manager, New Contract Year formulary evaluation, and rebate strategy evaluation.

The Clinical Pharmacist may review and present New Drug Entities, New Generics, and Line Extensions at the Plan’s Pharmacy & Therapeutics Committee Meeting.

This position will work with other constituents, including but not limited to: Pharmacy Director, Chief Medical Officer, Medical Director, Pharmacy team, Member Services, Utilization Management, IT/Analytics, Finance, Case Management, Provider Relations, Compliance, Sales/Marketing and the PBM account team.

Responsibilities

• Formulary Management and FRF submissions in HPMS
• Drug Monographs for New Drug Entity Reviews
• Development of Education Material for Providers
• Member Medication Reviews for identification of Polypharmacy, Inappropriate prescribing
• PBM Rebate Strategy implementation and oversight
• Pharmacy & Therapeutics Committee Meeting
• CMS Model Letter Reviews
• Coverage Determinations and monitoring of optimal cost effective drug management
• Perform medical necessity reviews for formulary exceptions and prior authorizations according to the Medicare Part D defined guidelines
• Work with the Pharmacy Benefit Manager (PBM) and formulary manager to manage formulary changes and update the Plan’s website to reflect the most up to date approved CMS versions of the formulary
• Assist providers with recommendations in an effort to promote cost-effective alternatives.
• Guide pharmacy technicians with clinical questions from prescribers, pharmacies, and/or members
• Ensure clinical alignment of drug management across medical and pharmacy benefits, including identification of new opportunities for drug management, safety programs, and medical/pharmacy cost savings
• Make recommendations on utilization management edits such as Prior Authorization, Step Therapy and Quantity Limits
• Provide internal professional staff education regarding the pharmacy benefit and formulary
• Assist with the development and implementation of the Pharmacy Department’s Policies and Procedures
• Responsible for pharmacy oversight of member communications including correspondence associated with coverage determination decisions
• Review prescription utilization data to identify outliers and trends, including high-cost drug category drivers
• Develop and implement cost-saving strategies for prescription drugs
• Evaluate medication regimens for members with polypharmacy and assist with medication reconciliation
• Develop educational material for prescribers to communicate pharmacy cost-management initiatives
• Visit prescribers one-on-one and effectively communicate cost-effective drug recommendations.
• Perform oversight of progress seen with pharmacy cost-saving initiatives.
• Provide feedback to the Pharmacy Director and other key players in the organization.
• Review prescription utilization data to identify outliers and trends, including high-cost drug category drivers
• Develop and implement cost-saving strategies for prescription drugs
• Evaluate medication regimens for members with polypharmacy and assist with medication reconciliation
• Develop educational material for prescribers to communicate pharmacy cost-management initiatives
• Visit prescribers one-on-one and effectively communicate cost-effective drug recommendations.
• Perform oversight of progress seen with pharmacy cost-saving initiatives.
• Provide feedback to the Pharmacy Director and other key players in the organization.
• Perform other projects, work, and activities as assigned by the Pharmacy Director

Qualifications

• Managed Care experience preferred, but not required
• Part D Coverage Determinations experience preferred, but not required
• Part D Formulary Management experience preferred but not required.
• HPMS Formulary Reference File (FRF) submission experience preferred but not required
• Strong computer skills, such as Microsoft Office (Outlook, Word, Excel, Powerpoint, Access). Programming or Reporting software skills
• Strong Communication and Presentation Skills
• Doctor of Pharmacy Degree (PharmD) or Bachelor of Pharmacy Degree (RPh) with clinical experience or Completion of, or currently enrolled in, residency program (PGY1) in managed care pharmacy, or pharmacy practice.
• Current and unrestricted State of Florida license.

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.