Health Plan Clinical Pharmacist I - Remote

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties.

About the role

This position is responsible for performing and/or supervising clinical pharmacist activities related to Pharmacy Quality Initiatives (e.g., MTMP, Adherence, CPAS, vHTN, ePA) for Kelsey-Seybold Clinic and/or KelseyCare Advantage. The clinical pharmacist works collaboratively with healthcare providers to ensure patients receive the proper medications and dosages for their conditions. If you are located in Texas, you will have the flexibility to work remotely.

Responsibilities

• Conduct clinical pharmacy services through Pharmacy Quality Initiative Programs, including:
  • Review of all current medications
  • Review pharmacy claims in contracted PBM systems
  • Screen for drug-drug interactions
  • Identify therapeutic alternatives
  • Communicate with physicians regarding drug therapy
  • Provide patient counseling
  • Perform medication reconciliation within EPIC (medical chart)
  • Follow-up with members
• Answer inbound calls and conduct outbound calls regarding processing of coverage determinations.
• Review medical information essential for coverage determination and enter data into software programs.
• Enter overrides in appropriate systems to process payment and generate letters/reports.
• Work all assigned program workflow steps and queues, including after-hours/weekend coverage as needed.
• Communicate with physicians and other healthcare personnel to discuss medication recommendations, cost-effective therapies, drug information, and educate about health plan prescription drug benefits.
• Monitor and evaluate claims for appropriate use by members, physicians, and pharmacies.
• Conduct drug utilization reviews for potentially fraudulent claims, abuse, and/or waste.
• Assist in reviewing claims adjudicated by the PBM to ensure correct payment for formulary products.
• Perform audits and report risks to management.
• Communicate instructions to internal and external individuals/departments and obtain information from other entities/vendors.
• Maintain staffing and program schedules.
• Assist in developing clinical pharmacy program enhancements and best practices, including RX Quality Initiative (RXQI), Pharmacy Quality Initiative Programs (QIP), Adherence Programs, Medication Therapy Management Program (MTMP), Hospital Discharge Program (HDP), Centralized Pharmacy Anticoagulation Service (CPAS), Fraud Waste and Abuse (FWA) protocols, and Coverage Determination (CD) processes.
• Provide program training and oversight, including training and oversight of program staff, pharmacy residents, and assigned interns.
• Assist in scheduling Health Plan Pharmacy Services Department personnel to ensure program productivity.
• Monitor daily duties and program work queues to ensure department goals are achieved.
• Create program reports (weekly, monthly, quarterly, annually, or upon request).
• Communicate program and staff concerns to management.
• Provide clerical support for Part D duties and audits, including administrative and clinical support for special projects.
• Attend and schedule meetings, manage calendars, handle dictation, answer phones, and address routine questions.
• Ensure prompt and courteous customer service by all Health Plan Pharmacy Services personnel.
• Ensure compliance with federal and state pharmacy laws.
• Triage patient emergencies and perform other duties as assigned.

Requirements

• Pharm.D. degree
• Current and active Pharmacy License and Texas State Board of Pharmacy (TSBP) Registered Pharmacist
• Customer service experience
• Proficient in alpha/numeric data entry with minimal errors
• Proficient with computer applications including Microsoft Word, Excel, and Access
• Demonstrated solid multitasking, problem-solving, and analytical skills
• Demonstrated ability to lead others on a team
• Proven detail-oriented with strong verbal and written communication skills, interpersonal skills, professional appearance, and ability to work effectively in a fast-paced environment
• Proven ability to communicate with all levels of management
• Excellent organizational skills

Preferred Qualifications

• Completion of a Managed Care Pharmacy Residency Program or Pharmacy Practice Residency Program (PGY1)
• ASHP Immunization Certification
• BLS Certification
• 1+ years of retail, HMO 3rd party managed care, or Medicare Part D experience
• Auditing experience
• Supervisory or management experience

Benefits

In addition to your salary, we offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).

Pay

The hourly pay for this role will range from $xx.xx to $xx.xx per hour based on full-time employment, depending on several factors including local labor markets, education, work experience, and certifications.