Clinical Pharmacist - Medical Policy

Residency in or relocation to Louisiana is preferred for all positions.

About the role

This position is responsible for leading the medical policy efforts of prescription drugs, including strategy development, implementation, build, maintenance, quality review, and measurement of the prior authorization program. This position also serves as a liaison to the clinical appeals area and serves as lead pharmacist on the Pharmacy and Therapeutics Committee.

This role does not manage people and reports to the Manager, Pharmacy Medical Policy & Specialty Drug Management. Necessary contacts include all levels of BCBSLA pharmacy department, clinical areas of Medical Management, PBM clinical personnel, e-hosting formulary vendor personnel, the Lead Medical Director for Medical Policy, and BCBSLA’s Medical Policy, Clinical Appeals, Professional and Facility Reimbursement, and Legal departments.

Responsibilities

• Serve as companywide subject matter expert regarding specialty drug management strategies of medications covered under both the pharmacy and medical benefits, including specialty pharmacy pipeline monitoring to identify new products expected to have major clinical and financial impacts on drug trend, ensuring coverage is current, clinically sound, and cost-effective.
• Serve as lead author of medical policy clinical criteria, including development, updating, and maintenance of decision tree logic used to support phone, fax, and web-based authorizations; ensure consistency of authorization requirements within therapy classes; monitor results of the authorization process (e.g., authorization, denial, and appeal rates) to ensure programs are current, clinically sound, efficient, and cost-effective.
• Serve as lead BCBSLA pharmacist to the Pharmacy and Therapeutics Committee; act as pharmacist liaison to the Clinical Appeal areas; lead review and discussion of drugs new to market, with new indications, or updated safety profiles; primarily accountable for change management functions resulting from the Annual Formulary Update process.
• Collaborate with pharmacy reporting and analytics to measure utilization management program effectiveness, identify medical and pharmacy drug dosing and utilization management opportunities, manage medical drug rebate programs, and provide rebate opportunity assessments.
• Responsible for maintenance and updating of self-administered drug list programming to ensure drugs intended for patient self-administration are not routinely reimbursed under the medical benefit.
• Perform other job-related duties as assigned, within scope of responsibilities.

Requirements

• Doctorate of Pharmacy or Bachelor's Degree in Pharmacy required.
• 1 year of experience working in clinical pharmacy roles and supporting P&T Committee and/or drug information activities required.
• 1 year of experience in managed care preferred.
• Experience with software programs such as Word and Excel is required; knowledge of PowerPoint preferred.
• Current pharmacy license in good standing required.
• Participation in ASHP or AMCP-accredited residency program preferred.

Skills

• Proficiency in pharmacology, therapeutics, and knowledge of disease management programs to support clinical aspects of the role.
• Strong interpersonal, organizational, oral/written communication skills, and strong clinical skills.

Physical Demands

• Job duties are performed in a normal, clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• Ability to comprehend, document, calculate, visualize, and analyze is required.