Clinical Quality Pharmacist

MedImpact Healthcare Systems Inc.; San Diego (CA); On-site; USD 109,000 - 196,000; Full time

Benefits offered by this job

Medical / Dental / Vision / Wellness |

Paid Time Off / Company Paid Holidays

Incentive Compensation

401K with Company match

Life and Disability Insurance

Tuition Reimbursement

Employee Referral Bonus

Job summary

MedImpact Healthcare Systems, Inc. in San Diego, CA is seeking a Clinical Quality Pharmacist to perform audits of PA and Appeals staff and Utilization management across all lines of business.

The role requires a PharmD and 3+ years of experience, with strong knowledge of NCQA/URAC standards and CMS Part D requirements. You will develop audits, analyze results, and report to leadership, ensuring compliance and high quality care.

Qualifications

• PharmD degree and 3+ years’ experience or equivalent combination.
• 1+ years of pharmacy practice in managed care, PBM, or health plan.
• Experience with NCQA/URAC and CMS Part D preferred.

Responsibilities

• Develops and implements clinical audits and reporting for all Client lines of business.
• Evaluates the accuracy of case reviews performed by PA and Appeals staff and UM delegates.
• Creates, administers, and manages IRR testing to ensure consistency amongst reviewers aligned with standards.
• Analyzes IRR results to identify trends, gaps, and opportunities for improvement, and provides detailed reporting to oversight committees.
• Prepares reports (e.g., Utilization Management Program Evaluation, quality reporting suite, IRR).

Skills

Clinical audits

Quality reporting

Regulatory compliance

Communication

Education

PharmD

Managed care exposure

Tools

Microsoft Office

Job description

Exemption Status: United States of America (Exempt) $108,515 - $152,464 - $196,412 “Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.” This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare. At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making.

Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description Summary

The Clinical Quality Pharmacist is responsible for performing clinical audits of Prior Authorization (PA) and Appeals staff and Utilization (UM) delegate(s) across all lines of business. This role involves interpreting, drafting, and modifying clinical-related documents and quality reports in alignment with regulatory and accreditation requirements, as well as Client requests.

Essential Duties and Responsibilities

Other duties may be assigned.

• Develops and/or implements clinical audits and reporting for all Client lines of business
• Evaluates the accuracy of case reviews performed by PA and Appeals staff and UM delegates
• Creates, administers, and manages inter-rater reliability (IRR) testing to ensure consistency amongst reviewers aligned with organizational and accreditation quality standards
• Analyzes IRR results to identify trends, gaps, and opportunities for improvement, as well as provides detailed reporting to oversight committees and leadership
• Monitors PA and Appeals processes and systems for improvement opportunities
• Reviews and assesses appropriateness of PA guideline requests, confirming applicability and compliance with established accreditation requirements
• Works closely with internal departments to resolve any non-compliance identified
• Meets with and provides audit reports to PA and Appeals leadership and staff
• Develops ways to reduce issues and improve quality through process or automation
• Responsible for quality assurance of PA and Appeals notifications meeting compliance with accreditation, regulatory, and client requirements
• Prepares reports (i.e. Utilization Management Program Evaluation, quality reporting suite, IRR)
• Develops client-facing communications focused on the organization’s quality assurance, compliance, and continuous improvement efforts
• Maintains department and company policies and procedures relating to quality.
• Supports maintaining MedImpact’s and its Clients’ NCQA and URAC accreditations.
• Supports the targeted audit program, including audits of drug categories, high-risk clinical programs, and other identified clinical risk areas.
• Supports delegation oversight activities, including audits, calibration sessions, reviewer training, and monitoring of corrective actions through closure.
• Other duties as assigned.

Supervisory Responsibilities

No supervisory responsibilities

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

PharmD and 3+ years’ experience or equivalent combination of education and experience, and 1+ years of pharmacy practice experience, including experience in managed care, PBM, or health plan setting in utilization management, clinical quality, or accreditation. Working experience with NCQA and/or URAC accreditation standards and CMS Medicare Part D requirements is strongly preferred.

Computer Skills

To perform this position successfully, an individual should have an advanced working knowledge of Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), Teams conferencing and messaging, standard PDF document tools, including the ability to create, combine, annotate, and complete fillable PDF documents.

Certificates, Licenses, Registrations

Active, unencumbered registered pharmacist license in at least one state in the United States is required.

Other Skills and Abilities

Excellent working knowledge of all types of pharmacy services (retail, home infusion, inpatient) with an emphasis on the managed health care environment. Managed Care residency, and/or other clinical experience is preferred.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Mathematical Skills

Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations. Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals.

Competencies

Composure Decision Quality Organizational Agility Problem Solving Customer Focus Drive for Results Peer Relations Time Management Dealing with Ambiguity Learning on the Fly Political Savvy

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).

Work Location

This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is an exempt level position requiring the incumbent to work the hours required to fully accomplish job responsibilities and reasonably meet deadlines for work deliverables. The individual must have the flexibility to work beyond traditional hours and be able to work nights, at weekends or on holidays as required. Work hours may be changed from time to time to meet the needs of the business. Typical core business hours are Monday through Friday from 8:00am to 5:00pm.

Travel

This position requires no travel; however attendance may be required at various local conferences and meetings.

The Perks:

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus

Equal Opportunity Employer, Male/Female/Disabilities/Veterans OSHA/ADA: To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Disclaimer: The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

MedImpact was founded more than three decades ago by a pharmacist and independent drug store owner who saw firsthand how families struggled with the high cost of prescriptions, and how it impacted their lives, financial security, and health. So, he started MedImpact to make prescription benefits understandable and accessible. While we have grown to be one of the leading PBMs in America, we remain as committed to these principles today as we did when it all began.