Clinical Pharmacy Solutions Specialist

2 weeks ago


Jersey City, New Jersey, United States Gainwell Technologies Full time

Position Overview


The role involves spearheading initiatives in the creation of clinical pharmacy solutions programs, which includes the development of prior authorization criteria and the organization of Pharmacy and Therapeutic Committee (P&T) and Drug Utilization Review (DUR) Board meetings.

The specialist will support both prospective and retrospective drug utilization reviews by analyzing physician prescribing behaviors, consulting with healthcare providers regarding these practices based on evidence-based methodologies, and collaborating closely with internal teams to enhance pharmacy management solutions.
The position requires coordination with various departments, including operations, clinical, medical, and reporting, as necessary.

Key Responsibilities

  • Analyze utilization trends observed in point-of-sale claim history.
  • Assess drug and drug class evaluations based on credible evidence-based research and methodologies recognized by the medical community, employing suitable approaches that align with high-quality evidence-based medicine principles.
  • Formulate clinical prior authorization criteria recommendations and documentation for presentation to the NJ DUR Board.
  • Organize NJ DURB meetings, prepare agendas, lead discussions, and maintain records of meeting minutes, action items, and follow-up tasks.
  • Review communications from prescribers and proactively engage with them to resolve any problematic claims.
  • Address clinical inquiries from staff, state agencies, and managed care organizations (MCOs).
  • Liaise with pharmacy chiefs and/or medical directors when necessary to seek guidance on complex claims.
  • Educate Gainwell pharmacy personnel on DURB-reviewed and recommended protocols or other relevant topics.
  • Prepare medical necessity forms corresponding to new protocols prior to their implementation.
  • Conduct both prospective and retrospective drug utilization reviews for state beneficiaries.
  • Participate in programming meetings for the rollout of approved protocols.
  • Generate weekly reports on NDC price changes.
  • Engage in quarterly meetings with MCOs and state staff.
  • Represent the state at fair hearings when requested.
  • Complete the DUR section of the annual CMS report and collaborate with state staff to review the finalized report before submission.
  • Manage inbound call volume from pharmacy providers and prescribers, ensuring accurate documentation of all communications.
  • Collaborate with state clinical staff during meetings with medical representatives for new drug presentations or current drug evaluations.
  • Regularly monitor prescription claims data and identify prescribing practices that are outliers through internal and external analyses to develop relevant retrospective DUR initiatives. Present these initiatives to the DUR Board, detailing methods, interventions, communications, and outcomes.
  • Contact physicians and prescribers identified as needing consultation to provide guidance on prescribing practices that have been flagged as outliers. Review prior authorization reports to identify opportunities for intervention.
  • Maintain the clinical integrity of pharmaceutical solutions by staying informed on medication information, contributing to the identification of best practices in pharmacy programs, collaborating with Medical Directors, and providing pharmacy expertise within the organization.

Qualifications

  • Preferred management experience in coordinating and collaborating with work teams.
  • Minimum of 5 years' experience in clinical pharmacy.
  • Proficient in conducting clinical reviews utilizing relevant compendia and clinical trial data.
  • Strong analytical skills capable of translating into practical recommendations.
  • Team-oriented with respect for all team members.
  • Excellent verbal and written communication skills.
  • Strong interpersonal skills essential for effective consultation with physicians, prescribers, and pharmacists, as well as for successful collaboration with company employees and external vendors.
  • Proficient in computer usage and internet navigation; basic skills in Microsoft Office products and the ability to quickly learn proprietary systems.
NJ State Licensure required

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