Senior Clinical Pharmacist

Viva-Health; Birmingham (AL); Hybrid; USD 110,000 - 150,000; Full time

Benefits offered by this job

Health insurance

401(k) Savings Plan with company match

Paid Time Off (PTO)

9 Paid Holidays plus Floating Holiday

Tuition Assistance

Flexible Spending Accounts

Community Service Time Off

Life Insurance and Disability Coverage

Employee Wellness Program

Job summary

Viva Health in Birmingham, AL seeks a Senior Clinical Pharmacist to provide leadership on clinical pharmacy decisions and programs within the health plan, including QA of coverage determinations and Part D review.

This role monitors drug utilization, supports CMS 4-Star goals, assists training, and collaborates with Pharmacy Benefit Managers to optimize formulary decisions and benefit administration.

Qualifications

• Pharmacist with PharmD and Alabama license.
• 3 years in health plan or Medicare with PGY1 residency or 5 years in health plan/Medicare provider.
• Strong regulatory interpretation and CMS guidance knowledge.
• Proven leadership in clinical pharmacy programs.
• Ability to train staff and QA activities.

Responsibilities

• Lead clinical pharmacy decisions and programs for the plan.
• QA coverage determinations and serve as reviewer for Part D.
• Monitor drug utilization, policies, and costs for quality and cost-effectiveness.
• Train new pharmacists and support CMS Star Rating efforts.
• Collaborate with PBMs on formulary and benefits management.
• Prepare updates for committees and audits.

Skills

Leadership

Clinical Pharmacy

Quality Assurance

Regulatory Knowledge

CMS Medicare

Communication

Microsoft Office

Education

PharmD

Alabama Pharmacist License

Tools

RX Claims System

Microsoft Office

Job description

Bham-Corporate Office
Birmingham, AL 35203, USA

Description

Location: Birmingham, AL

Work Schedule: Hybrid schedule with regular work onsite at the VIVA HEALTH corporate office and some work-from-home opportunities.

The Senior Clinical Pharmacist will provide leadership at the health plan regarding clinical pharmacy decisions and programs. This position will assist departmental leadership with Quality Assurance (QA) of coverage determinations reviewed by the Clinical Pharmacist, serve as a clinical reviewer for the Plan's Medicare Part D Coverage Determinations, and serve as the subject matter expert for Opioid Part D reporting requirements.

This individual will monitor prescription drug utilization, coverage policies, and costs to identify and address issues related to quality and cost-effectiveness. This role will assist in training of new pharmacists and support the Pharmacy Department's efforts towards attainment of a minimum 4 Star CMS Medicare Advantage Plan Star Rating.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Assist with QA of coverage determinations reviewed by the clinical pharmacists and report findings to management.
• Maintain and apply criteria for drug related coverage determinations, exception requests, complaints, and appeals and ensure criteria and decisions are properly communicated and applied. Research individual cases and render decisions in consultation with the Pharmacy Department Management or Medical Director if required.
• Assist in training of new coverage determination pharmacists.
• Create and maintain training guides and job aids for the pharmacists to use when reviewing coverage determinations.
• Support pharmacists and management with maintenance and development of policies and procedures as required by CMS regulations.
• Assist management with preparation for regulatory reviews and audits and participate as needed.
• Participate in on-call rotation for coverage determinations to satisfy CMS requirements and regulations, including periodic weekend and holiday work.
• Assist the Department in monitoring drug cost and utilization trends in aggregate and on a patient specific basis to identify quality issues as well as clinically appropriate cost-saving opportunities. Assist with development and implementation of procedures for addressing these opportunities such as physician and member communications (one-one or general), programs in conjunction with internal or external stakeholders, and benefit/formulary adjustment recommendations.
• Collaborate with the Pharmacy Benefit Manager(s) (PBM) and assist with clinical oversight of benefit administration. This includes formulary selection and maintenance, application of utilization management tools (prior authorization, step therapy, quantity limits, etc.), review of member disruption related to formulary changes and drug recalls, and drug review criteria.
• Attend and prepare clinical updates for the Plan's oversight committees as needed including the Pharmacy & Therapeutics Committee and Utilization Management/Quality Improvement Committee.
• Develop and present training, reports and other communications for internal staff, providers, and other stakeholders related to clinical pharmacy issues, such as drug pipeline information.
• Participate in development and execution of strategies to support achievement of a 4 Star minimum CMS Medicare Advantage Plan Star Rating.
• Serve as the subject matter expert for Opioid Part D reporting requirements.
• Participate in Pharmacy Student mentoring, education, and development as needed.

REQUIRED:

• Registered Pharmacist (Rph) or Doctor of Pharmacy (PharmD)
• 3 years' experience working in a health plan or Medicare provider with PGY1 residency or 5 years' experience working in a Health Plan or Medicare Provider
• Licensed Pharmacist in good standing with the State of Alabama
• Good computer skills including Microsoft suite of products
• Ability to prioritize effectively and collaborate with all levels of associates
• Ability to interpret regulatory technical guidance and apply it to daily work
• Knowledge of Medicare Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

PREFERRED:

• Health care related degree or master's degree (MBA, MSHA, MM, MPH, etc.)
• Experience in the RX Claims system
• Board Certified Specialist (BCPS, BCGP, etc.) and/or a health care related certification (ex: MTM certification)
• Knowledge of health plan pharmacy benefit administration processes

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.