Highmark Health Senior Pharmacist in Home, Pennsylvania
Gateway Health Plan
Job Description :
This job works in a team oriented environment. The incumbent monitors FDA-approvals, drug manufacturer pipelines, and assess drug utilization reports, in order to develop and execute the Organization's Drug Formulary, and/or recommends codes for pharmaceutical based reporting. The incumbent writes drug monographs for Committee review; develops and implements the Organization's management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling, pharmacy policy review and development and/or review of member specific information to improve individual outcomes as an adjunct to health coaching. The incumbent also reviews UM requests; provides consultation into the case and disease management identification process, and consults with the Organization's Associate Medical Directors and Medical Directors when appropriate, follows-up on appeals in accordance with our regulatory guidelines. The incumbent develops and implements physician, pharmacy, account, and member educational initiatives that promote the Organization's Formularies, utilization management programs, and case/ disease management initiatives; provide clinical review and decisions for physician and member appeals and participate on cross-functional committees to develop and implement clinical and operational initiatives.
Monitor FDA-approvals, drug manufacturer pipelines, assess drug utilization reports, and write drug monographs for
Committee review to develop the Organization's Drug formulary and/OR provide recommendations for NDC code capture, and monthly identification of high risk members.
Assist in the development of the Organization's Drug Formularies by monitoring FDA-approvals and drug manufacturer pipelines, assessing drug utilization reports, and writing drug monographs for Pharmacy & Therapeutics Committee review.
Assist in the development and implementation of utilization management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling medical policy review and development, member facing outreach initiatives.
Develop and implement physician, pharmacy, account, and member educational initiatives that promote the Organization's Formularies, utilization management programs, and disease management initiatives.
Provide clinical review and decisions including but not limited to: physician and member appeals, member or provider information/education.
Participate on cross-functional committees to develop and implement clinical and operational initiatives within Integrated Clinical Services. May participate in outreach efforts as needed to effectively reach goals of Medication Therapy Management programs to include, but not limited to Comprehensive Medication Reviews and Targeted Medication Reviews.
Identify and assist in managing department process improvements to maximize overall efficiencies.
Manage individual projects for timely review with the Director, Clinical Pharmacy.
Participate in Medicare Stars performance measures to drive contribution to excellence (5 Stars).
Other duties as assigned or requested.
Bachelor of Science in Pharmacy with experience in clinical / formulary management or a Doctor of Pharmacy degree with experience in clinical formulary management
5 or more years of related, progressive experience in the area of specialization
An understanding of managed care principles and practices is essential
Demonstration of strong verbal and written communication skills, as well as, proficiency in the use of computer-based data processing. Microsoft Office products, and database applications is required
A candidate should be able to quickly identify and prioritize essential elements of problem
Independently or in a team, a candidate should be able to identify the root issues and formulate potential solutions
It is imperative that the candidate accurately use logic and reasoning in identifying alternate solutions, conclusions or approaches to problems
Potential solutions should be synthesized into presentation, timetable to resolution and appropriate follow up with measurable outcomes
Utilize Monograph and literature reviews to determine recommendations for formulary changes
Complete member case reviews for appropriate recommendations
Initiate and coordinate individual projects including determining timetables, metrics and monitoring for outcomes
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
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Req ID: J159908