clinical pharmacy specialist coverage review - Grand Rapids, MI, United States - Corewell Health

Description

Job Summary

Not able to hire remote in California or New York.

Managed care pharmacists are responsible for ensuring patient access to appropriate and cost-effective medication therapies.

Pharmacists in this role support a variety of services including developing and implementing evidence-based clinical programs and quality-oriented drug management services, instituting practices to ensure patient safety, communicating and collaborating with patients, prescribers, pharmacists, internal and external clients, contributing to the design of pharmacy benefits, managing quality and cost effectiveness, and involvement in the medication distribution process in the managed care setting.

Essential Functions

• Performs day to day clinical pharmacy functions including prior authorization and appeal reviews.
• Uses clinical expertise to make coverage determinations and ensure adherence to prior authorization protocols, formulary status, medical necessity and contract criteria.
• Analyzes pharmacy and medical spend data (total cost of care, drug and medical trends) and coordinates development of appropriate use standards, prior authorization protocols, and guidelines.
• Supports drug formulary development and management.
• Participates in strategies and clinical programs that ensure appropriate and cost-effective medication use, through principles of drug utilization management and medication optimization.
• Works with medical directors, pharmacy leaders, and medical management teams to provide drug information support to promote optimal quality of care and efficient use of resources.
• Participates in clinical and operational process improvement and cost savings opportunities.
• Supports clinical initiatives related to NCQA, HEDIS, CAHPS, STAR measures, and other clinical quality and programs. Adheres to Pharmacy Policies and Procedures.

Qualifications

• Required Doctorate Doctor of Pharmacy degree from an accredited College of Pharmacy
• Licensed Clinical Pharmacist in state of residence required
• 3 years of pharmacist experience or managed care residency preferred
• PharmD preferred
• Managed care/Health Plan/PBM experience preferred
• Oncology, Specialty Pharmacy, Infusion, high-cost medication experience
• Residency training or credentials:

BCPS, CSP, or BCOP preferred

Primary Location

SITE - Priority Health E Beltline - Grand Rapids

Department Name

PH - Pharmacy Operations

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8 a.m. to 5 p.m.

Days Worked

Monday to Friday

Weekend Frequency

On-call weekends

CURRENT COREWELL HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community.

We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category.

We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization.

As a health system, we advocate for equity as we care for our patients, our communities, and each other.

From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do.

We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling

People are at the heart of everything we do, and the inspiration for our legacy of outstanding outcomes, innovation, strong community partnerships, philanthropy and transparency.

Corewell Health is a not-for-profit health system that provides health care and coverage with an exceptional team of 60,000+ dedicated people-including more than 11,500 physicians and advanced practice providers and more than 15,000 nurses providing care and services in 22 hospitals, 300+ outpatient locations and several post-acute facilities-and Priority Health, a provider-sponsored health plan serving more than 1.2 million members.

Through experience and collaboration, we are reimagining a better, more equitable model of health and wellness.