Pharmacist I

Job Description

Note: Oncology & Compounding experience preferred.

Responsibilities:

• Review’s physician inquiries for pharmacy, physician-administered, or home infusion pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria.
• Forwards initial denials to appropriate queue for further review.
• Generates notification letters to members and physicians on approved and denied requests.
• Handles calls and correspondence from providers; responds to inquiries, complaints and reconsiderations.
• Documents calls in inquiry tracking system.
• Using established protocols ensures resolutions provided are presented in a clear and accurate manner.
• Receives escalated calls that cannot be clinically resolved by 1st level intervention.
• Research, resolves and responds to provider clinical inquiries.
• Supports Fraud and Abuse program system oversight.
• Communicates any suspected fraud discovered by the contact center staff.
• Recommends course of action for providers where patterns appear outside of guidelines and generally accepted pharmacy standards.
• Serves as second line contact for all internal pharmacy related issues.
• Functions as clinical liaison between internal staff and pharmacy network participants.
• Ensures internal changes that may affect network services are reflected in the claims processing system.
• Conducts research necessary to maintain Prior Authorization Criteria, including therapeutic category and comparative drug review.
• Works with appropriate individuals/vendors to facilitate compliance.
• Responds to and drafts correspondence to physicians regarding requests on Drug Formulary.
• Responds to telephone inquiries from physicians, other healthcare professionals and members regarding select drug information.
• Keeps abreast of industry trends and regulatory changes in the pharmacy industry and evaluates their effect on pharmacy contracts and services.
• Makes recommendations on program improvements, based on findings and utilization.

Requirements:

• Current pharmacy license in NY.
• 2 years pharmacy experience preferred.
• Oncology & Compounding preferred.