Pharmacy Resident

MetroPlusHealth; New York (NY); On-site; USD 55,000 - 70,000; Full time

Job summary

MetroPlusHealth in New York is seeking a Pharmacy Resident to audit and validate benefit configurations, support formulary management, and strengthen patient care across all lines of business. The role emphasizes clinical program development, medication reconciliation, and care management through rotations.

The resident will advance evidence-based decision making, collaborate with clinical teams, and contribute to quality initiatives, audits, and education for staff on new therapies and

Qualifications

• Doctor of Pharmacy degree required.
• Experience in a managed care environment preferred.
• Experience in auditing preferred.
• Experience in Pharmacy management of government programs (Medicaid and Exchange) preferred.
• Experience in the evaluation and interpretation of pharmacy claims data is preferred.
• Proficiency with MS Word, Excel, and PowerPoint is required.

Responsibilities

• Reviews daily claims reports to identify accuracy of pharmacy benefit configuration across lines of business.
• Reviews daily rejection reports to identify inconsistencies affecting patient care.
• Validates improper coding between POS and UM platforms.
• Coordinates care between members, pharmacies, and providers to improve adherence.
• Assists in formulary and utilization management for medications across lines of business.
• Develops drug monographs and coverage criteria upon request.
• Completes retro utilization reviews for drugs of interest and analyzes results.
• Participates in quality initiatives and monthly KPI reports.

Skills

Auditing

Teamwork

Education

Doctor of Pharmacy (PharmD)

Tools

MS Word

Excel

PowerPoint

Job description

Empower. Unite. Care. MetroPlus

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers.

Position Overview

The Pharmacy Resident is responsible for auditing and validating internal and external reports to ensure proper benefit configuration across all lines of business. The Pharmacist Intern will also assist in all other Pharmacy department directives. Additionally, the Pharmacist Intern is responsible for assisting the Clinical Pharmacy Manager with all aspects of formulary management, care management and utilization management strategies across all lines of business. The Pharmacist Intern will be responsible for improving patient care through various clinical programs, medication reconciliation, counseling and care management in the form of rotations. This resident will have opportunities to develop evidence-based clinical decision making, project management, analytic and leadership skills.

Work Shifts

9:00 AM - 5:00 PM

Duties & Responsibilities

• Reviews daily claims reports of varying focuses across all lines of business to identify and report on the accuracy of the pharmacy benefit configuration.
• Review daily rejection reports to identify and report on inconsistencies or concerns that may impact patient care.
• Validates improper coding through verification between Point of Sales (POS) and Utilization Management (UM) platform systems.
• Coordinates care between members, pharmacies, and providers to improve patient adherence for chronic medications and to promote other pharmacy initiatives including assisting with pharmacy case management activities.
• Review daily reports to ensure all overrides are inputted correctly and claim adjudication is as intended.
• Assists in preparing documentation for internal and external audits and regulatory submissions.
• Reaches out to members, pharmacies, and prescribers to reconcile benefit inconsistencies.
• Reviews external communications for accuracy and appropriateness.
• Assists with prior authorization requests including inputting, providing notification for and reviewing needed.
• Complete core and elective rotations.
• Assists with formulary and utilization management for medications across all lines of business.
• Develop drug monographs and coverage criteria upon request.
• Completes retro utilization review for drugs of interest and provides in depth analysis.
• Develops and maintains various pharmacy quality initiatives and generates regular monthly reports for key performance indicators.
• Provides education to staff on new therapies, new criteria, new guidelines to ensure internal pharmacy staff are versed on up-to-date trends.
• Assists in Pharmacy case management programs to improve quality of care and monitoring of MetroPlusHealth members.
• Assists in organizational and departmental quality improvement initiatives

Minimum Qualifications

• Doctor of Pharmacy required.
• Pharmacy experience in a managed care environment is preferred.
• Experience in auditing preferred.
• Experience in Pharmacy management of government programs (Medicaid and Exchange) preferred.
• Experience in the evaluation and interpretation of pharmacy claims data and other clinical data is preferred.
• Proficiency with MS Word, Excel, and PowerPoint is required.

Licensure And/or Certification Required

• Valid Pharmacy Intern Permit issued by the New York State Education Department (NYSED).

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Position requires excellent organizational, teamwork, interpersonal, time management, written and verbal communication skills

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