Clinical Pharmacist

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

POSITION SUMMARY

The Clinical Pharmacist will report directly to the Director of Pharmacy and will assist in activities related to the daily operations of the pharmacy services department, and the Medicare/Medi-Cal Rx pharmacy benefit including performing drug utilization review; fraud, waste and abuse monitoring and detection; clinical program development; education of pharmacies and pharmacists; participating as a member of the Pharmacy and Therapeutics (P&T) Committee; participate in appeals, grievances and complaints regarding pharmacy services; participate in provider education initiatives regarding Medicare/Medi-Cal Rx; analyze individual provider prescription reports; support the Director of Pharmacy on strategic planning and roadmap development for clinical programs to impact health outcomes and quality metrics (e.g. MCAS, HEDIS, STARS); attend medical education meetings and disease management initiatives including quality endeavors that pertain to the use of pharmaceuticals.

Amount of Travel Required: 10-20%

Work Schedule: Travel to multiple sites and different locations. Flexibility to work beyond normal business hours as needed.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

* Pharmacy Network Management: Educate the provider network regarding Medi-Cal Rx and Medicare Part B and D benefits, pharmacy claims, and pharmacy benefit procedures; Address providers' pharmacy questions and inquires; Work with GCHP on all DHCS, CMS, DMHC, NCQA, and HEDIS audits when appropriate; Work with other departments involved in the provision of pharmacy services; Establish policy and procedures and internal processes.

* Pharmacy Cost Oversight and Management: Conduct analyses of pharmacy utilization; Develop and review standardized pharmacy utilization reports for internal customers, including drug, physician, patient and pharmacy provider specific analysis; Prepare quarterly therapeutic drug class reviews of pharmacy utilization for the P&T Committee, and other internal committees as needed; Develop utilization tracking reports; Assist in the development of a program for monitoring specialty drugs; Participate in CMS meetings related to the Medicare prescription drug benefit; Manages Part B drug trend and value-based opportunities.

* Drug Utilization Review: Conduct drug utilization review; Assist in the development of over and under-utilization review reports and identify and conduct member and provider interventions; Prepare quarterly reviews of drug utilization for the P&T Committee, Utilization Management Committee, and Quality Improvement Health Equity Committee.

* Medication Therapy Management: Provide medication therapy management including examination of member medical records; Performing a comprehensive medication review and communicate with patients and providers, including outbound calls to patients to discuss their medications; Participate in Integrated Care Team (ICT) meetings and provide recommendations for optimizing medication regimens for the cases presented and reviewed.

* Medicare D-SNP: Oversee PBM operations in the areas of Formulary, Opioid Safety Edits, Pharmacy Benefits, Transition Programs, Prescriber Enrollment Requirements and Pharmacy Network implementation; Coordinate strategies for increase medication adherence; Ensure effective collaboration with internal and external partners to support clinical programs; Provide support to programs targeted toward the Medicare membership; Researches and responds to Part D grievances and inquiries; Conducting outreach to prescribers, pharmacies and members as needed; Reviews Part B and D coverage determinations and appeal requests and make clinical decisions in accordance with formulary benefits, guidelines and CMS requirements; Assist with conducting oversight audits and focus on continuous monitoring activities; Maintains current knowledge of Medicare Part D regulations by participating in CMS calls and reading released guidance and implementing changes to maintain compliance.

* Support for GCHP Staff: Provide training to GCHP staff regarding issues and updates related to pharmacy operations; Contribute relevant articles for the various newsletters as requested; Update the GCHP Pharmacy Services web pages; Collaborate with other departments on assigned projects or tasks; Participate in special projects and assignments as needed and other duties as assigned; Perform other related duties as required or assigned.

POSITION QUALIFICATIONS

Competency Statements

* Management Skills - Ability to organize and direct oneself and effectively supervise others.

* Business Acumen - Ability to grasp and understand business concepts and issues.

* Communication, Written - Ability to communicate in writing clearly and concisely.

* Communication, Oral - Ability to communicate effectively with others using the spoken word.

* Customer Oriented - Ability to take care of the customers' needs while following company procedures.

* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

SKILLS & ABILITIES

Required Education:

* Bachelor's Degree in Pharmacy or Doctorate in Pharmacy from an accredited school of pharmacy is required.

* Completion of pharmacy residency and/or fellowship preferred.

Minimum Qualifications

* Minimum of 3 years of experience in a health plan or a pharmacy benefits manager (PBM) or successful completion of a managed care or pharmacy practice/clinical residency required.

* Must have Managed Care experience or pharmacy benefit management experience or equivalent.

* Minimum 2 years of work experience with Medicare Part D required.

* Ability to demonstrate strong analytical, organizational, and communication skills

* Strong critical thinking skills

* Ability to work in a fast-paced and agile work environment.

* Must possess knowledge of the principles of pharmacoeconomics, as well as drug utilization, current medical practice standards and appropriate medication usage

* Ability to work with multiple software computer programs in the development of pharmacy reports

* Proven ability to communicate effectively, both orally and in writing

* Proven ability to maintain accurate records

* Basic knowledge of the Medi-Cal program.

Preferred Qualifications:

* Previous work experience in Medicare Part D formulary management.

* Previous work experience in Medication Therapy Management.

* Previous work experience in prior authorization approval or drug utilization review.

* Previous work experience with Medicare STARS.

* Knowledge of DHCS, DMHC, NCQA and/or CMS regulatory requirements is desired.

Computer Skills: Advanced computer skills included in the MS Office products.

Certifications & Licenses:

* Current, unrestricted California Registered Pharmacist (RPh) license in good standing.

* A valid and current Driver's License, Auto Insurance, and professional licensure(s) required.