Clinical Pharmacist

Job Description

Job Summary:

• Complete Clinical Reviews and provide a determination of Medicare-Medicaid Coverage Determination/Redetermination, Medical Review, Global Exception et cetera, by following established clinical process.
• Continually monitor the quality and efficiency of the Prior Authorization process including coverage criteria, denial language, and communication with prescribers and members.
• Provide recommendations to physicians to improve medication regimens as appropriate.

Duties & Responsibilities:

• Complete Clinical Reviews and provide a determination of Medicare-Medicaid Coverage Determination/Redetermination, Global Exception etc.
• By reviewing all requests which are not clearly approvable based on specified criteria (algorithms).
• Continually monitor the quality and efficiency of the Prior Authorization process including coverage criteria, denial language, and communication with prescribers and members.
• Provide recommendations to physicians to improve medication regimens as appropriate.
• Complete all annual NCQA, Client required training requirements.
• Assists Member Services and other internal customers in responding to and resolving pharmacy-related inquiries from members (NCQA Requirement).
• Maintain open lines of communication with other functional areas/departments.
• Responsible for staying current with clinical literature and guidelines and relaying those to the program development core teams.

Required Experience:

• Background/Experience (Required)Proficiency in Microsoft Excel, Word, Outlook, and SharePoint.
• Superior written and verbal communication skills.
• Will considered a recent grad with an active license.
• Preferred)Managed care experience (Medicaid/Medicare).
• 1+ year of previous clinical pharmacy experience required.
• 2+ years of experience working as a pharmacist (managed care experience is highly desirable, but not required).
• Knowledge of clinical program components, formulary designs, and prescription benefit trends preferred.
• Board certification and managed care residency preferred.

Required Education:

• Pharm D. required.
• Must have an active license in good standing.
• License should be active within the state they reside in with no history or restrictions.