Clinical Pharmacist Consultant - Portland, United States - Cambia Health Solutions, Inc

Description

Clinical Pharmacist Consultant

Remote in ID, OR, WA, UT

Primary Job Purpose

Provides clinical pharmacy expertise and applies evidence-based medicine to determine medication coverage. This may include providing coverage recommendations for medications subject to prior authorization, appeals, retrospective claim reviews, and audits based on applicable medication coverage policies, member benefit contracts, and provider contracts. In addition, the pharmacist will serve as a resource regarding clinical, policy, and benefit questions and interventions for other staff, such as medical directors or case managers. May also provide direct outreach to members and providers.

This role may also assist in developing and implementing clinical strategies with respect to formulary management, drug utilization management, peer-to-peer conversations, drug education, and/or case management strategies. Advanced responsibilities may include analyzing health care cost information, development of position papers, medication coverage policies, formulary monographs, and cross-functional projects.

General Functions and Outcomes

• Responsible for delivering high quality pharmacy clinical services for Medication Benefit Management.
• May be responsible for conducting prior authorization reviews and peer-to-peer conversations with external providers.
• Provide coverage recommendations for medications subject to prior authorization, appeals, retrospective claim reviews, and audits based on applicable medication coverage policies, member benefit contracts, and provider contracts.
• Provides sound clinical decision-making based on best practice in applying evidence-based medicine process in determining medications that have best value for efficacy and safety.
• Develops and provides informational materials and correspondences to providers and members to communicate medication coverage choices, comparative effectiveness, and coverage determinations.
• Provides creative thinking and leadership in accomplishing goals of quality improvement and cost-effective prescription drug programs.
• Collects, analyzes, interprets, and forecasts health care cost information based on current prescribing patterns based on medication utilization reports.
• May develop position papers, medication coverage policies, formulary monographs, and formulary coverage recommendations based on critical appraisal of the scientific literature and input from practicing providers.
• Presents and/or communicates clinical positions on medication analysis in a clear, concise manner.
• May present formulary and medication coverage considerations to internal and external decision-making bodies such as the Pharmacy and Therapeutics Committee and Medication Policy Group.
• May identify, develop, implement, and track complex cross-functional programs, projects, and initiatives related to the provision of pharmacy benefits that impact safety, quality, and affordability.
• May support the execution, development, and maintenance of clinical programs.
• May empower Case Management to provide comprehensive member support.

Minimum Requirements

• Strong clinical pharmacy background with ability to demonstrate clinical skills and knowledge in a clinical care setting.
• Demonstrated success in managing professional relationships in a managed care system, medical group, hospital, pharmacy, or related organizations.
• Excellent verbal and written communication skills, strong business analytical abilities, and strong project management and coordination abilities.
• Ability to work independently on long term projects.
• Strong knowledge of medications, state and federal laws and regulations regarding the practice of pharmacy, and regulation of health care industry practices.
• Strong knowledge of health care economics, health care/pharmaceutical industry dynamics, and pharmacy/provider service medication reimbursement.
• Knowledge of health plan and benefit design structures and application, Medicare/CMS regulations and applicability in administering the Medicare Product, and health care coding and payment systems (such as ICD-9, CPT, HCPCS, NDC).
• Knowledge of compliance related activities, legislative and regulatory activities, health insurance operations, and legal issues.
• Ability to collaborate as part of cross functional teams, improve clinical programs, enhance processes, and share clinical information.
• Ability to work independently, prioritize work, meet deadlines, and achieve operational goals.

Normally to be proficient in the competencies listed above:

Clinical Pharmacist Consultant would have a Bachelor's degree in Pharmacy or Doctor of Pharmacy (PharmD) or related field and 3-5 years of experience in clinical acute care/hospital setting or equivalent combination of education and experience.

Required Licenses, Certifications, Registration, Etc.

Pharmacy license. Successful completion of a pharmacy residency or advanced degree in health-related field preferred. Must be an active and unrestricted licensed pharmacist in state of practice.

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