The Clinical Specialist manages accessibility, quality, and cost-effectiveness of drug and medical therapy for members and providers. This position focuses on initiating, supporting, and continuing cost-effective, rational drug, and disease therapy, utilizing distinct but inter-related management and cross-departmental functions.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
Responsible for providing clinical support services to client plan(s) contracting for clinical services; Support services will include, but not limited to, clinical review, analysis, recommendation, decision and documentation of prior authorization requests, medical exception requests, and appeal requests as required by client contracts and Utilization Management delegation agreements
Review medication request guidelines for clinical appropriateness and operational efficiency; Assist in the revision and creation of new or existing medication request guidelines as indicated
Provide drug information support; Research and provide clinical literature documentation to support prior authorization decisions as indicated; May include preparation of Pharmacy and Therapeutics meeting agenda and associated meeting materials including clinical and financial reviews of individual drugs, drug classes, and current therapy for specific disease states and drug formulary review
Coordinate and assist in the preparation of utilization and compliance reporting for client plans; Ensure timely preparation and review of plan data and client presentations, when required
Coordinate and assist with projects associated with prior authorization program development, implementation and internal and external communications
Provide feedback to Prior Authorization Coordinators (PACs) regarding the processing of PA cases referred for clinical review; Provide in-service education to PACs regarding topics such as PA guidelines, diagnoses commonly seen as part of the PA review process
Education and/or Experience
For consideration, candidates will need to have a Pharmacy degree (Pharm. D.) or equivalent and two (2) to five (5) plus years of job related experience and/or training, or an equivalent combination of education and job related experience.
To perform this job successfully, an individual should have knowledge of Microsoft Office Suite Word Processing software.
Certificates, Licenses, Registrations
Current, unrestricted Registered Pharmacist license in the State of California or a state of the United States
Other Skills and Abilities
Excellent working knowledge of all types of pharmacy services with an emphasis on the managed health care environment
Expertise in clinical application of pharmacy practice
This position is eligible for Employee Referral Bonus at Level IV
To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.