Clinical Operations Pharmacist

Responsibilities

• Responsible for the pharmacy utilization management (UM) reviews.
• Uses clinical expertise and independent judgment to evaluate prior authorization (PA) to determine if request meets established PA criteria, clinical medical policies, or clinical medical necessity (CMN) criteria.
• Maintain and support pharmacy UM programs and provide implementation support for formulary management decisions and clinical policies.
• Aids in the creation, maintenance of administrative, and utilization management policies.
• Supports the medical cost savings strategy including, but not limited to, executing UM reviews for high cost medications and evaluating complex treatment plans are medically appropriate.
• Make clinical UM recommendations of these for leadership level review.
• Engages ordering providers in discussion related to CMN.
• Documents all aspects of PA review process within PA software application per NCQA standards.
• Provides pharmacy-related customer service to external and internal parties.
• Serves as drug information resource for internal departments (e.g., Care Management, Medical Directors, Grievance and Appeals Unit).
• Provide ongoing leadership & support to Pharmacy Technicians in order to ensure that day-to-day service and production goals are met.
• Provide peer trainings and assist with onboarding of new employees.
• Maintains current knowledge of and ensures compliance with government and federal regulations.
• Committed to regulatory adherence to meet turnaround time requirements set by our State and Federal regulators.
• Committed to evaluate quality controls.
• Responsible to audit cases to ensure compliance of regulatory requirements and to evaluate quality improvement opportunities.
• Follows best practices to maintain high production and quality standards to deliver excellent provider, member, and employee experience.
• Continuously look for ways to streamline and improve operational workflows.
• Effective planning, organizational and decision-making skills; ability to handle multiple high priority projects with competing deadlines.
• Supports the documentation of processes required for day-to-day operations.
• Demonstrates a strong understanding of all lines of business (LOB) including benefit design and regulatory requirements per LOB.
• Performs other duties as assigned that may include, but not limited to:
• Oversight of daily operational duties and work with senior leadership to de-escalate issues.
• Support departmental projects when assigned.
• Maintain daily, weekly, monthly, quarterly and annual operational metrics to ensure optimal and comprehensive operational efficiency and accuracy.
• Analyze, report, trend, solution and escalate findings from the routine reports and provide education to pharmacist staff on areas of opportunities.
• Engages with pharmacy department vendors on operational items to ensure appropriate escalation and resolution.

Qualifications

• Registered Pharmacist – active, unrestricted license in the state of Rhode Island (Consideration will be given to individuals without current RI license. Must provide documentation confirming RI Pharmacist application within 24 hours of offer)
• Bachelor’s Degree in related field and/or PharmD
• Minimum of one (1) years’ experience working as a Pharmacist
• Strong analytical skills
• Strong clinical skills
• Ability to resolve issues and complete required duties with little supervision
• Good verbal and written communication skills including presentation skills
• Intermediate to Advanced skills in Microsoft Office (Word, Excel, Outlook)
• Flexibility in work schedule. Ability to work evenings and weekends