Clinical Pharmacist

Clinical Pharmacist

Position Summary / Position

Under the direction of the Manager, Clinical Pharmacist, the Clinical Pharmacist is responsible for the daily operation of clinical programs and prior authorization activities.

The Clinical Pharmacist should demonstrate the ability to participate in multidisciplinary teams to provide comprehensive care to Members through Clinical Programs including Medication Reconciliation, Medication Therapy Management, and other departmental initiatives.

Major Functions (Duties and Responsibilities)

1. Preparation of medication reconciliation reviews for post-discharge, comprehensive medication reviews (CMRs), and other medication management programs that includes reviewing chart notes, electronic medical records, and / or relevant clinical information within compliance turnaround times and quality standards meeting regulatory requirements as defined by Department of Health Care Services, Center for Medicare & Medicaid Services, California Department of Managed Health Care, and National Committee for Quality Assurance.

2. Clinical oversight for activities related to the medication therapy management (MTM) programs including targeted medication reviews (TMRs) and comprehensive medication reviews (CMRs), and other related activities for Members, Providers, and pharmacies.

3. Review and respond to interdepartmental tasks sent via MHK, Meditrac, Care Director, or any other systems required and coordinate the care of the member as necessary with the other departments such as Member Services, Health Ed, Care Management / Behavioral Health, Compliance, etc.

4. Communicate with Providers and Member (in English and Spanish) providing information and assistance as appropriate.

5. Provide excellent customer service on all outbound calls. This includes but is not limited to the following : demonstrating a high level of patience and respect with every call subject, avoiding distractions to ensure each call subject is assisted promptly and appropriately ensuring a positive provider / member experience.

6. Communicate with providers (doctor and pharmacy) and members on issues related to the medication reconciliation, medication therapy management, prior authorizations or respective policies and procedures.

7. Decision prior authorizations according to established treatment protocols, clinical medication criteria, clinical practice guidelines and monographs and within compliance turnaround times and quality standards meeting regulatory requirements as defined by Center for Medicare & Medicaid Services, California Department of Managed Health Care and National Committee for Quality Assurance.

8. Research clinical information to maintain drug and disease state knowledge for application to prior authorization review and clinical programs.

Attend seminars and trainings to learn about different disease states and respective medication therapy management and drug utilization review.

9. Ensure regulatory reporting requirements and fraud and abuse reporting are met for all clinical and prior authorization operations.

10. Participate in multi-disciplinary team (Primary Care Provider, Case Manager, UM Nurse, etc.) to discuss the ongoing needs of Members, which include, but not limited to medication regimen review and consultations.

Attend case management discussions and / or rounds to review medication therapies and provide medication assessments.

11. Provide clinical education, guidance, and support to maintain productive working relationships with team members, other internal and external Providers, and management team operations and ensure adherence to standard work.

12. Attend quarterly Pharmacy & Therapeutics meetings to participate in clinical discussions and review. Provider quarterly post Pharmacy & Therapeutics education on updates, new criteria, and pertinent clinical information to the Pharmacy Program Specialist team members.

13. Perform peer review auditing and quality assurance checks to ensure clinical decision making and clinical recommendations meets the regulatory and company standards.

14. Assist with direction on the Provider webpage as needed.

15. Actively participate in internal quality improvement process enhancements, LEAN projects, and managing for daily improvement (MDI).

16. Participate in various pharmacy projects to meet the standards of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS).

17. Ensure all departmental goals (including, but not limited to turnaround, production expectations, and quality metrics) are met.

18. Ensure all company’s goals (including, but not limited to the 5 Strategic Priorities : Quality of Care and Service, Access to Care, Practice Transformation, Human Development and Technology and Data Analytics).

19. Exhibit behavior as referenced in the Handbook (i.e. attendance, dress code, electronic device policy, personal behavior).

Experience Qualifications

Three (3) or more years of individual or combined experience in pharmacy, hospital, or drug benefit related quality assessment, utilization management and / or provider liaison duties.

Minimum of one (1) year Managed Care residency OR Ambulatory Care residency.

Education Qualifications

Doctor of Pharmacy (Pharm. D.) from an accredited institution required.

Professional Licenses

Possession of an active, unrestricted, and unencumbered Registered Pharmacist license issued by the California State Board of Pharmacy.

Drivers License Required

Bilingual (English / Spanish) preferred.