The main function of a pharmacist is to dispense prescription medications to patients and offer expertise in the safe use of prescriptions.
They also may conduct health and wellness screenings, provide immunizations, oversee the medications given to patients, and provide advice on healthy lifestyles.
Job Description
Position Purpose:
Provide timely drug therapy for Medicaid health plan members by processing prior authorization and medical necessity requests
Direct resources to individual cases, projects, or critical needs.
Update health plan pharmacy documentation in conjunction with state laws.
Maintain relationships with all health plan pharmacy leadership regarding escalated claims
Implement, maintain and provide training on all departmental process and procedural documents, including prior authorizations
Manage prior authorization requests and pharmacists’ determinations for drug products according to member benefits and coverage criteria
Provide clinical guidance and support to the assigned pharmacists and pharmacy technicians
Responsible for setting criteria for medication analysis, coordinate reports to clients, meet regulatory reporting requirements for drug utilization review and fraud and abuse reporting
Develop clinical criteria for review of non-formulary or non-preferred drug lists medications and communicate recommendations to clients
Oversee the drug utilization review and medication therapy management programs at the assigned plan to meet Medicare Part D requirements and develop systematic reviews of prescription claims to meet strategic initiatives
Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practices
Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Education/Experience
Bachelor’s degree or advanced degree (PharmD., M.S) in pharmacy. 3+ years of retail or hospital pharmacy experience or 1+ years of managed care pharmacy experience. Clinical pharmacy experience in managed healthcare preferred.
License/Certification
Current state’s Pharmacist license with no restrictions. An additional license may be required as needed by state or contract.
Seniority level
Mid-Senior level
Employment type
Contract
Job function
Health Care Provider
Industries
Staffing and Recruiting
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