Clinical Pharmacist I

Education Preferred:
Doctor of Pharmacy preferred
Graduate study in a business, public health, or health policy field
Experience Required:
At least 5 years clinical experience or completion of an accredited residency program required

Experience Preferred/Desirable:
Experience in direct supervision of technical support staff for clinical and/or service and operational programs is desirable.
Experience in a managed care setting, either from the provider, the payer, or the PBM side of the industry, is preferred.

Required Licensure, Certification or Conditions of Employment:
Successful completion of pre-employment background check
Unrestricted current and valid license to practice pharmacy in the state of Massachusetts and/or in any other relevant/applicable state
MTM Certification is desirable

Reporting to the Manager of Clinical Pharmacy Operations, the Clinical Pharmacist I (UM) is primarily responsible for the pharmacy utilization management (UM) activities, including review of all pharmacy prior authorization requests, oversight of the UM activities of the Pharmacy Services support staff, maintenance of pharmacy UM programs, provide clinical peer-to-peer consultation as needed, provide pharmacy-related customer service to internal and external parties, and serve as a subject matter expert for claims issue resolution. In addition, the Clinical Pharmacist I (UM) may provide implementation support for formulary management decisions and clinical policies and provide peer trainings as needed. The Clinical Pharmacist I (UM) may also participate in care management activities as needed.

Key Functions/Responsibilities:

Participation in prior authorization, formulary exception, step therapy and quality limit program implementation and management for all lines of business
Conduct pharmacy prior authorization decisions consistent with covered benefits, clinical policies, medical necessity for both pharmacy and medical distribution channels
Ensure that pharmacy prior authorization requests and decisions are properly evaluated, documented and are compliant with all regulatory and accreditation requirements
Provide oversight of Pharmacy Operations analysts in executing day-to-day approvals and denials in order to maintain compliance with all regulatory requirements.
Support product portfolio, which includes rotational weekend and holiday support for timely determinations.
Provide clinical peer-to-peer consultations
Responsible for analysis and issue resolution as it pertains to the administration of the formulary and benefits
Provide pharmacy-related customer service to both internal and external parties.
Responsible for insuring pharmacy programs meet applicable industry, regulatory, accreditation and contractual standards or laws
Collaborate with clinical and non-clinical teams for staff trainings, facilitation of meetings and other ad hoc presentations.
Participate in the development and design of drug utilization programs and new clinical program opportunities
Facilitate special projects as assigned
Develop drug information, training, and support to all internal and external customers
Develop strategies for effective communication of program initiatives in partnership with Clinical Pharmacy for internal and external customers
Identify opportunities for workflow efficiencies and new clinical quality and cost saving programs

Supervision Exercised:
May provide guidance and direction to pharmacy operations specialists

Supervision Received:
General supervision received weekly

Competencies, Skills, and Attributes:
Excellent written and oral communication skills
Excellent interpersonal skills
Strong organizational and time management skills, including ability to work independently and prioritize multiple projects and assignments
Demonstrated strength in analysis, identification of problems and issue resolution
Excellent skills in teamwork and team approaches to goal setting and attainment
Must be results oriented
Proficiency in standard computational office-suite applications, including word-processing and relational database manipulation is required


Physical location Restrictions:
Alabama
Arizona
Colorado
Connecticut
Florida
Georgia
Idaho
Illinois
Indiana
Kansas
Kentucky
Maine
Maryland
Massachusetts
Michigan
Minnesota
Missouri
Nevada
New HampClient
New Jersey
New Mexico
New York
North Carolina
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin