Clinical Pharmacist
3 weeks ago
Position Summary:
Under the direction of the Manager, Pharmacy Program, the Clinical Pharmacist is responsible to review prior authorizations, provide clinical recommendations to Providers, and provide clinical education and guidance to the pharmacy team.
This position is Remote after onsite orientation for Southern California residents only.
Responsibilities:
- Review medication prior authorization requests according to established treatment protocols, clinical medication criteria, clinical practice guidelines, and monographs.
- Decision prior authorizations within compliance turnaround times and quality standards meeting regulatory requirements as defined by Department of Health Care Services, Center for Medicare & Medicaid Services, California Department of Managed Health Care, and National Committee for Quality Assurance.
- Ensure all departmental goals (including, but not limited to turnaround, production expectations, and quality metrics) are met.
- Ensure all company’s goals (including, but not limited to the 5 Strategic Priorities: Quality of Care and Service, Access to Care, Practice Transformation, Human Development, and Technology and Data Analytics).
- Communicate the medication prior authorization clinical decision with Providers.
- Assist in providing clinical information, recommending formulary alternatives, and educating on pharmacy benefits to Providers, Members, and Pharmacy Program Specialist team members.
- Provide open lines of communication with Pharmacy Providers on issues related to formulary or pharmacy policy and procedures.
- Research clinical information to maintain drug and disease state knowledge for application to prior authorization reviews and appeal cases. Attend seminars to learn about different disease states and respective medication therapy management.
- Provide clinical education, guidance, and support to Pharmacy Program Specialist team members to review prior authorizations and ensure adherence to standard work.
- Provide monthly clinical disease state and/or drug category education to Pharmacy Program Specialist team members.
- Develop guidelines, processes, and standard work to assist Pharmacy Program Specialist team members process prior authorizations accurately and efficiently.
- Coordinate prior authorization and drug utilization reviews to ensure regulatory reporting requirements and fraud and abuse reporting are met.
- Make recommendation(s) for addition, changes, and/or deletions to the medication formulary.
- Actively participate in quality improvement process enhancements, LEAN projects, and manage for daily improvement (MDI) visual management.
- Participate in a multi-disciplinary team (Primary Care Provider, Case Manager, UM Nurse, etc.) to discuss the ongoing needs of Members, which include, but not limited to medication regimen review and consultations. Attend case management discussions and/or rounds to review medication therapies and provide medication assessments.
- Demonstrate ability to maintain productive working relationships with team members, other internal and external Providers, and management team
- Provide clinical support to the prior authorization team for claims review.
- Review pharmacy-related appeals and work with Medical Directors on decision-making. Attend monthly appeals meetings and discussions as part of an interdisciplinary team with medical directors.
- Attend quarterly Pharmacy & Therapeutics meetings to participate in clinical discussions and reviews. Provider quarterly post Pharmacy & Therapeutics education on updates, new criteria, and pertinent clinical information to the Pharmacy Program Specialist team members.
- Perform peer review auditing and quality assurance checks to ensure clinical decision-making meets the regulatory and company standards. Participate in weekly case review discussions to review quality assurance findings.
- Participate in Medical Services appeals meetings or other activities as needed.
- Provide mentorship and leadership training to Pharmacy Program Specialist team members.
Experience Qualifications
- Minimum of 1-year Managed Care residency.
- Or three (3) or more years of individual or combined experience in pharmacy, hospital, or drug benefit-related quality assessment, utilization management, and/or provider liaison duties.
Preferred Experience
- Clinical residency preferred.
- Preferable experience in an HMO or Managed Care setting.
Education Qualifications
- Doctor of Pharmacy (Pharm. D) from an accredited institution is required.
Professional Licenses
- Possession of an active, unrestricted, and unencumbered Registered Pharmacist license issued by the California State Board of Pharmacy.
Company DescriptionCross Country Workforce Solutions Group (CCWSG) is a human resource, consulting and talent acquisition firm, specializing in PACE Programs, FQHCs/CHCs, and State Healthcare plans throughout the US. Our national operations center is located in Southern California.
CCWSG provides clinical and non-clinical staffing support to PACE centers across the country; we are the nation’s exclusive provider of non-medical, in-home caregivers for the elderly enrolled in PACE programs. Currently, we have over 3,000 caregivers supporting patients in their homes through PACE.
We are a part of the Cross Country Healthcare family, a market-leading workforce solutions, tech-enabled talent platform, and staffing, recruitment, and advisory firm with almost 40 years of industry experience and insight. We are a full-service partner, combining market expertise and services, including contingent staffing, consulting, human capital, management solutions, recruitment process outsourcing, vendor management, and direct hiring.Company DescriptionCross Country Workforce Solutions Group (CCWSG) is a human resource, consulting and talent acquisition firm, specializing in PACE Programs, FQHCs/CHCs, and State Healthcare plans throughout the US. Our national operations center is located in Southern California.\r
CCWSG provides clinical and non-clinical staffing support to PACE centers across the country; we are the nation’s exclusive provider of non-medical, in-home caregivers for the elderly enrolled in PACE programs. Currently, we have over 3,000 caregivers supporting patients in their homes through PACE.\r
We are a part of the Cross Country Healthcare family, a market-leading workforce solutions, tech-enabled talent platform, and staffing, recruitment, and advisory firm with almost 40 years of industry experience and insight. We are a full-service partner, combining market expertise and services, including contingent staffing, consulting, human capital, management solutions, recruitment process outsourcing, vendor management, and direct hiring.
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