SUMMARY
The Clinical Pharmacist ensures Leon Health members have access to all medically necessary prescription drugs that are used in a cost-effective and safe manner and that the pharmacy benefit programs follow all federal and state laws. Responsibilities include those involved in formulary management (such as, reviewing prior authorization requirements, reviewing drug/provider utilization patterns, and pharmacy costs management), clinical pharmacy services (such as therapeutic drug monitoring, drug regimen review, patient education, and medical staff interaction), and oversight (establishing and measuring performance metrics regarding patient outcomes, medications safety, and medication use policies).
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Communicates decisions for pharmacy requests according to clinical guidelines and company policies.
- Evaluates pharmacy requests received by telephone, facsimile, and other tools using plan’s clinical criteria and determines appropriateness for medications.
- Communicates decisions to physicians, physician’s office staff, medical management staff, members, and pharmacists.
- Performs clinical research to support requests and analyzes what further information needs to be collected to complete patient records.
- Performs electronic or verbal outreach (i.e., e-mail, fax) to pharmacies and physician's offices to obtain all necessary information related to requests, including member assistance, when needed.
- Performs non-medical research including eligibility verification, coordination of benefits, and Part D benefit verification.
- Maintains accurate and complete documentation of required information following regulatory requirements and company policies.
- Guarantee drug requests comply with all federal and state laws.
- Effectively communicate with Case Managers, other health plan staff, and health plan providers.
- Promotes communication, both internally and externally, to enhance the effectiveness of pharmacy services.
- Escalates requests to Pharmacists when request requires extensive clinical review or denial.
- Assist with members' inquiries related to the formulary process.
- Demonstrates courtesy and politeness to patients, visitors, callers and other employees.
- Maintains open channels of communication with center administration and other company departments; Answers all inquiries in a professional and courteous manner.
- Participates in training and in-service education as required.
- Participates in department, clinic and other meetings as requested.
- Complies with the organization's policies and procedures and maintains confidentiality in accordance with state and federal laws.
- Participates in special projects and performs other duties as assigned.
QUALIFICATIONS
- At least three (3) years of experience as a Pharmacy Technician reviewing, designing and configuring details of the pharmacy claims processing and/or formulary maintenance systems as well as supporting comprehensive coordination of Medicare Part D pharmacy services including intake and processing of pharmacy authorization requests
- Current/recent Pharmacy Benefit Manager (PBM), or managed care pharmacy experience preferred
- Proficiency in computerized pharmacy systems and software applications.
- Deep Medicare part D claims experience.
- Demonstrated working knowledge of the English language and ability to communicate verbally and in writing.
- Knowledge in pharmacy practices, procedures, and ability to read and understand pharmaceutical information.
- Working knowledge of drug dosage forms, drug strength, generic and trade name equivalent.
- Demonstrates knowledge of Federal and State laws/regulations regarding provisions of pharmacy services.
- Ability to multi-task and prioritize work.
- Ability to adjust based on business/department needs.
- Effective communication (listening, verbal and written) skills.
- Proficient in Microsoft Word, Excel, and Outlook required.
- Good organization/attention to detail.
- Members and providers call center experience preferred.
- Intermediate level of proficiency in MS Excel (writing formulas, filtering and working with large data sets
EDUCATION
High School Diploma
LANGUAGE SKILLS
Bilingual English/Spanish fluency.
CERTIFICATES, LICENSES, REGISTRATIONS
- A valid Florida Pharmacy Technician Licenses
- National Certification (CPHT)
PHYSICAL DEMANDS/WORK ENVIRONMENT
Work schedule is approximate and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including on weekends and holidays. Position requires the ability to work extended hours when necessary.
The physical demands and work environment characteristics described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors.
