Clinical Pharmacist

Position Summary:

The Clinical Pharmacist will be responsible for reviewing high-cost drug requests and validating adverse coverage determinations before final decisions are rendered. They will work in conjunction with Medical Directors to render final decisions on coverage determinations.

The Clinical Pharmacist will evaluate scientific evidence to select appropriate medications for a patient population and assess clinical data regarding new medications with the Pharmacy and Therapeutics Committee.

This role will serve as a clinical resource for both internal and external customers in regards to the high-cost drugs-prior authorization pharmacy program.

Essential Duties and Responsibilities:

• High Cost Drugs (Injectable and Infusions) Prior Authorization
• Review up to 14 prior authorizations daily in accordance with Health Plan turnaround time and formulary guidelines and requirements.
• Perform day-to-day clinical pharmacy functions including prior authorizations and appeal reviews.
• Make clinical decisions in accordance with evidence-based guidelines for medical necessity, safety, and tried and failed medications.
• Utilize drug references and verify the drug being requested is indicated and approved for the condition based on CMS guidelines, Health plan guidelines, and the FDA.
• Perform scientific literature evaluations using nationally approved resources to support decision-making and recommendations to providers.
• Analyze, research, and resolve prior authorization processing issues, including making written or telephone inquiries to obtain information from clients, members, physicians, or pharmacies; obtaining input from the VP of Pharmacy Services, and High Risk Drug team.
• Document all related information regarding prior authorization-related information and status for approval or non-approval clearly and easily accessible.
• Protect and maintain confidentiality and privacy of all prior authorization and member information, including following strict protocols for date stamping and storage/security of prior authorization forms and related information.
• Participate in Pharmacy and Therapeutics Committee meetings and support quality improvement projects.
• Conduct trainings for new employees/interns/training on PA protocols/policies.
• Assist in daily turnaround time reports (1x daily).
• Review Triage report up to 3x daily.
• Review OOC report (1x daily).
• Guide team with complicated cases/authorizations, reviewing audit findings, and participate in weekly/monthly team meetings.
• Perform other duties/projects as assigned from the VP of Pharmacy.

Compensation and Benefits:

The pay range for this position at commencement of employment is expected to be between $120,000 - $130,000 annually; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Requirements:

A current, valid, unrestricted California State Pharmacy License and Pharm.D. is required. Pharmacy Residency, PGY-1 (Preferred). Board of Pharmacy Specialty (BPS) certification (Preferred). Advanced Practice Pharmacist (APP) license (Preferred). Current knowledge and expertise in clinical pharmacology and disease states required. Ability to exercise independent judgment and prioritize a diverse workload. Outstanding organizational and communication skills. Proficient understanding of common computer programs used in pharmacy practice, and the ability to type at least 30 words per minute is preferred. Knowledge, understanding, and experience in reviewing and decision-making in prior authorizations. Ability to solve problems and work efficiently based on turnaround times. Strong communication and interpersonal skills. Knowledge of insurance policies and prior authorization processes.