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   Current UPMC employees must apply in HR Direct

Clinical Pharmacy Specialist - Prior Authorization Team

Description

UPMC Health Plan is hiring a full-time Clinical Pharmacy Specialist to support the Pharmacy Services department on the Prior Authorization Team. This is a work-from-home position, working daylight hours Monday through Friday located anywhere in the United States.

Registration as a registered pharmacist (RPh), in the Commonwealth of Pennsylvania or eligibility for licensure by examination or reciprocity is required.

The Clinical Pharmacy Specialist provides clinical pharmacy expertise to the development, implementation and management of the pharmacy benefit. The clinical pharmacist assists in the management of pharmacy utilization and provides expertise in managing member care. These services will be provided in compliance with state and federal regulations, NCQA, standards, the mission, policies and procedures of Health Plan and Pharmacy Department. Individual should demonstrate professionalism and commitment to meet UPMCHP goals and objectives.
 


Responsibilities:

  • Administrative: Maintain a solid understanding of the requirements of the Pennsylvania Department of Health, DHS, CMS and the National Committee for Quality Assurance, specifically as they relate to the expectations of pharmacy operations. Ensure compliance with regulatory and accreditation requirements of clinical functions. Participate in meetings, committees, and work groups both internally and externally as assigned.
  • Clinical Activities: The following may be assigned depending on department needs. Develop and revise various formularies for each line of business (commercial, Medicare, Medicaid), including sending communications, training of identified departments, updating all brochures, updating the website, and submitting change forms. Research adequately and be properly prepared for all P&T Committee meetings, ensuring all recommendations for both new drugs and new policies are appropriate and have been discussed with subject matter experts. Present these assignments succinctly and at a suitable pace, volume, and speed and answer all questions. Develop and conduct Drug Utilization Review (DUR) activities, Medication Therapy Management (MTM), and other integrated programs with medical management. Create, develop, maintain and enhance clinical reporting programs, including but not limited to physician specific reporting, alternative prescribing programs for utilization, assigned client plans, etc. Manage and evaluate therapeutic drug interventions and other clinical pharmacy programs for the purpose of controlling pharmacy trend, including member and provider interventions, and looking specifically at outcomes for these programs, as well as considering comprehensive research projects. Pipeline monitoring and evaluation. Provide innovative and applicable ideas in clinical program development, utilization management, formulary management, provider education, therapeutic substitution, MTM/DUR, and/or improvements in programs and edits that already exist, including both improving operational efficiencies, as well as developing new clinical edits. Implement these new ideas or improvements as approved, while also considering outcomes in all programs. Work with employer clients, account management, and sales in client and member meetings as assigned to improve the understanding of the pharmacy benefit, as well as offering recommendations.
  • Communication: Foster and maintain collaborative relationships with internal and external customers. Communicate pharmacy information as appropriate to members, employer groups, and providers. Develop communication materials to providers, including discussions regarding formulary changes/adherence, health education, medication compliance, and trend management as assigned.
  • Operational Activities: Critically review medication based prior authorization requests for approval/denial against standard criteria. Review and participate in member appeal cases, including hearings. Support the pharmacy call center by answering the phone queue to assist call representatives. Review new drugs in a timely manner and submit change forms as appropriate as assigned.
  • Special Skills/Ability to Interact: Have ability to function independently, but support team concept. Behavior denotes reliability as demonstrated by prompt attendance and timeliness completing designated workload and follow-up. Conveys and maintains professional image while interacting with coworkers, providers and clients. Honor client and patient confidentiality. Performs in accordance with system-wide competencies/behaviors. Performs other duties as assigned.
  • Teaching and Education: Mentor students, and assist in precepting for the residency program as assigned.

Qualifications

  • Bachelor of Science Degree in Pharmacy, and/or Doctor of Pharmacy Degree (Pharm.D.) from an accredited U.S. School of Pharmacy.
  • Experience in pharmacy benefit management, insurance, managed care preferred and be knowledgeable in therapeutic interventions and other cost containment programs.
  • Effective communication skills, both written and oral.
  • Must have strong analytical ability and organizational skills.
  • Computer literacy for pharmacy programming, word processing, data management.Assessment of job related skills and competency will be reviewed annually via daily functioning, job-related documentation, department based competency programs, and continuing education activities.

    Preferred Experience:
    (1) PA Pharmacist - Managed care residency or 1-3 years managed care experience, preferably in the development and execution of multiple utilization management techniques such as prior authorization, step therapy, quantity level limits, and other dose optimization techniques.
    (2) Product Development Managed care residency or 1-3 years managed care experience in formulary development and management, especially in Medicare, Medicaid, Commercial and/or Exchange lines of business.(
    3) Care Management - Managed care residency or 1-3 years managed care experience or at least 3 years of direct patient pharmacy practice experience, engaging in counseling and clinical services.


Licensure, Certifications, and Clearances:
Registration as a registered pharmacist (RPh), in the Commonwealth of Pennsylvania or eligibility for licensure by examination or reciprocity.Continuing Education requirements met each bi-annual cycle for re-licensure, as evident by obtaining a minimum of 30 hours of continuing education every 2 years in structured pharmaceutical education as necessary by the state board
 

  • Pharmacist


    UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct