Provide utilization management for drug therapies including; review of prior authorization requests to make determinations for drug therapy according to member benefits and coverage criteria, creation and maintenance of Pharmacy and Medical drug therapy guidelines, development of clinical criteria for review of non-formulary or non-preferred drug requests, and determination and maintenance of applicable prescription limitations (age, gender, quantity, etc.)
Review prior authorization requests and make determinations for drug products according to member benefits, established treatment protocols and clinical criteria
Make coverage determinations within the defined turnaround times and meet regulatory requirements
Responsible for clinical criteria including analysis, monitoring of the industry trends and assist in development of the criteria for the Pharmacy and Therapeutics Committee
Develop and design clinical edits to adjudicate claims and enhance drug utilization
Provide clinical guidance and support to the assigned pharmacy technicians
Develop and review guideline criteria for prior authorization and non-formulary drugs in support of Pharmacy and Therapeutics Committee function and pharmacy benefit design
Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy procedures
Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Assist to develop and design specialty medication clinical edits for claims adjudication and enhanced drug utilization review
Provide clinical guidance and support for systematic reviews of prescription claims to meet strategic initiatives
Reviews policies and procedures related to pharmacy issues
Works in collaboration with Prior Authorization Supervisor to help with workflows and operational efficiencies
Provides input into pharmacy technician functions to improve clinical decision making
Reviews and resolves complaints made by members and providers regarding Prior Authorization, formulary or pharmacy services
Participates in support of the Pharmacy and Therapeutics Meeting to review and keep current Drug Formulary
Knowledge of utilizing LexiComp, Facts and Comparisions, Micromedex, UptoDate, National guidelines, NCCN etc.
Collaborate to create clear communication to members and/or providers on prior authorization determinations
Work in partnership with pharmacy staff to assist in the implementation of utilization management programs
Educate pharmacy staff on specific utilization management guidelines and processes
Collaborate with the Pharmacy Director to determine clinical edits to adjudicate claims and enhance drug utilization (e.g. create and maintain coverage policies for quantity limits, step therapies, age/gender limitations)
Continuously work to streamline and improve the quality of the drug utilization management strategy process and Prior Authorization process
Be available as a clinical resource to all BCBSSAZ internal staff regarding medication therapy
Assist in the training and mentoring of pharmacy students
Support the determination, appeal, and grievance process for the retail, mail order, specialty, and medical prescription benefits
DEMONSTRATES EFFECTIVE MANAGEMENT SKILLS:
Motivates and manages staff to ensure that performance standards are met or exceeded.
Ensures that adequate in-service education is available to staff members.
Demonstrates the ability to make decisions, take appropriate action and follow tasks through to completion.
Recognizes and analyzes the implications of new situations and develops workable solutions to maintain productivity and morale.
Acts as a role model in demonstrating the customer service standards of the Organization.
Demonstrates a commitment to personal growth and development by participating in external activities related to professional goals.
Responds cooperatively to managers and staff members in other departments to promote teamwork.
Attends administrative meetings as appropriate and contribute ideas for improving efficiency, productivity and customer satisfaction.
Attends all mandatory education and training courses.
Maintain effective working relationships to ensure teamwork in achieving corporate goals.
Participate in quality initiatives; including functions that support audits, reporting, evaluation of quality opportunities and concerns, and creation and implementation of corrective actions as requested.
Coordinate activities between multiple divisions to achieve desired results.
The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
Perform all other duties as assigned.
Required Work Experience
1 year of experience with specialty medications or direct prior authorization experience
1 year of c urrent experience in Diabetes, Cholesterol, Hypertension, Asthma/COPD management Required Education
Doctor of Pharmacy (Pharm.D) degree Required Licenses
Active, current and unrestricted State of Arizona (a state in the United States) pharmacist license
Preferred Work Experience
5 years as a practicing pharmacist
3 years of experience in the managed care pharmacy field
2 years of direct prior authorization experience
1 year of experience with ACA formulary and utilization management
2 years of experience with Medicare Part D formulary and utilization management
Working knowledge of MediSpan data system, including GPI drug classification system
1 year of current experience performing drug efficacy-cost analysis Preferred Education
Pharm. D with residency or fellowship preferred Preferred Licenses
Board Certified Ambulatory Care Pharmacist (BCACP)
Certified Geriatric Pharmacist (CGP) Preferred Certifications
Certified Diabetes Educator (CDE)