POSITION SUMMARY
Performs administrative duties related to the monitoring, planning, organizing, and managing of the PEHP Pharmacy benefit. Serves as a pharmacy benefits expert, interprets and communicates benefits and programs, pre-authorization and appeal approvals and denials with physicians, members and PEHP employees. Directly involved in the functions of the Pharmacy and Therapeutics Committee.
ESSENTIAL DUTIES & RESPONSIBILITIES
- Provides pharmaceutical advice and consultation for disease management, utilization management, cost containment, quality assurance, and drug related quality improvement activities.
- Serves as a pharmacy benefits expert in interpreting and communicating pre-authorization and appeal approvals and denials with physicians, members, PEHP Customer Service, PEHP Case Management, and the PEHP Benefits Department.
- Collaborates with other health care professionals to plan, monitor, review, and evaluate the quality and effectiveness of drugs and drug regimens.
- Coordinates pharmacy plan requirements with PBM management, third party contacts, and PEHP policies and plans. Serves as liaison between PBM, drug manufacturers and PEHP regarding electronic claims, drug formularies, drug utilization review (DUR), and other drug programs.
- Responsible for the interpretation of PEHP policies and literature research when reviewing member and provider pharmacy appeal and second level pre-authorization requests.
- With direction from the Pharmacy Services Manager and Medical Director, assists in the development of authorization criteria and pre-authorization recommendations based on technical knowledge, FDA guidelines and literature reviews.
- With direction from the Pharmacy Services Manager develops prior authorization criteria and adherence programs.
- Implements pharmaceutical care policies and procedures to ensure compliance with existing standards, practices and funding source regulations.
- Provides complex clinical analysis of drugs. Makes recommendations on therapeutic effectiveness and analyzes drug treatment. Recommends drugs to be covered on the pharmacy formulary.
- Analyzes prescribing trends to monitor compliance and to prevent excessive usage or harmful interactions.
- Provides specialized services to help patients manage conditions such as diabetes, asthma, smoking cessation, or high blood pressure.
- Assists in evaluating clinical and financial data to make recommendations on drugs to be covered on the pharmacy formulary.
- Prepares and presents drug information and financial data to the pharmacy and therapeutics committee.
- Provides information to members on the selection of medication and related drug supplies.
- Maintains strict confidentiality.
- Performs other related duties as required.
Minimum Requirements:
Doctor of Pharmacy Degree from an ACPE accredited school of pharmacy. Minimum of three years of progressively responsible pharmacy experience.
Previous experience within a managed care organization is preferred.
Course work or degree in areas of Business Management, Health Administration, Health Financing and Insurance Management is desirable.
Currently licensed to practice pharmacy in the state of Utah required with a clean licensing history record without infractions.
Must be able to obtain unrestricted certificates with the Drug Enforcement Agency.
Knowledge, Skills, and Abilities
Requires considerable knowledge of drugs and drug prescription practices; considerable knowledge of PBM processes, pharmacy claims adjudication policies, procedures and processes; intricacies related to drug pricing, usage, dosage and drug definitions and codes, formulary practices, pharmacy electronic systems; and researching methods.
Must have the ability to draft technical reports, documents, manuals and instructions; analyze a variety of management issues and problems and make recommendations and decisions; communicate effectively verbally and in writing; ability to follow written and verbal instructions; establish and maintain effective working relationships with professionals, executives (public and private), department management, co-workers and the public; work independently and deal effectively with stress caused by work load and time deadlines.
Job duties require occasional travel for office business. Individual must be physically capable of safely operating a vehicle, possess a valid license and have an acceptable driving record based upon data provided by a current Department of Motor Vehicle Record (MVR).
Work Environment
Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing and seeing. Common eye, hand, finger dexterity required to perform essential functions.
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