Primary Job Purpose
The Clinical Pharmacist Consultant provides professional and clinical expertise for Pharmacy Services' clients in making clinical decisions based on best practices by applying evidence-based medicine evaluations to determine the best quality medication choices that represent the best value in efficacy, safety and affordability. This includes providing coverage recommendations for medications subject to prior authorization, appeals, retrospective claim reviews, and audits based on applicable medication coverage policies, member benefit contracts, and provider contracts.
This role may also assist in planning, developing, and implementing clinical strategies with respect to formulary management, drug utilization management, medication therapy management programs, quality initiatives, gaps in care, peer to peer conversations and drug information and education. Advanced responsibilities may include analyzing health care cost information, development of position papers, medication coverage policies, formulary monographs and class reviews, cross-functional projects, and initiatives related to the provision of pharmacy benefits that impact safety, quality and affordability.
General Functions and Outcomes
- Responsible for delivering high quality clinical services for Pharmacy Services' clients for Medication Benefit Management.
- Responsible for conducting peer clinical reviews. (The medical director has the responsibility to determine that the peer clinical reviewers are qualified to render a clinical opinion for items under review.)
- Responsible for peer to peer conversations.
- Works independently within framework and guidelines to evaluate intangibles associated with cost-containment and quality improvement of prescription drug charges.
- Provide coverage recommendations for medications subject to prior authorization, appeals, retrospective claim reviews, and audits based on applicable medication coverage policies, member benefit contracts, and provider contracts.
- Provides clinical decision-making based on best practice in applying evidence-based medicine process in determining medications that have best value for efficacy and safety.
- Develops and provides educational materials and correspondences to members to inform them about medication coverage choices, comparative effectiveness, and coverage determinations.
- Provides creative thinking and leadership in accomplishing goals of quality improvement and cost-effective prescription drug programs.
- Collects, analyzes, interprets, and forecasts health care cost information based on current prescribing patterns based on medication utilization reports.
- Develops position papers, medication coverage policies, formulary monographs and class reviews, and formulary coverage recommendations based on critical appraisal of the scientific literature and input from practicing physicians to ensure optimal clinical outcomes at most cost-effective level.
- Presents and/or communicates clinical positions on medication analysis in clear, concise manner.
- Presents formulary and medication coverage policy considerations to internal and external decision-making bodies such as the Pharmacy and Therapeutics Committee and Medication Policy Group.
- Identify, develop, implement and track complex cross-functional programs, projects, and initiatives related to the provision of pharmacy benefits that impact safety, quality and affordability.
- Provides professional services and expertise related to clinical pharmacy practice, evidence-based medicine, and drug products to support the care team, care for patients, support consumers, impact population health, and contribute to the development and maintenance of the digital health platform and suite of products.
- This role may participate in the design and implementation of population-level initiatives and medication management strategies delivered via the digital health platform. May also participate in the design of product features
- Clinical pharmacy background with ability to demonstrate clinical therapy skills and knowledge in a clinical care setting.
- Demonstrated success in managing professional relationships in a managed care system, medical group, hospital, or related organizations.
- Excellent verbal and written communication skills; strong business analytical skills and abilities; strong project management and coordination ability.
- Knowledge of pharmaceutical products, including orals, injectables, infusion products, and chemotherapy; state and federal laws and rules regarding the practice of pharmacy and regulation of health care industry practices, such as DOLI, PPACA and HIPAA.
- Strong clinical pharmacy background with ability to demonstrate clinical therapy skills and knowledge in a clinical care setting.
- Strong knowledge of health care economics and financing; health care/pharmaceutical industry dynamics; and pharmacy/provider service reimbursement of medications.
- Knowledge of Health Plan and benefit design structures and application; Medicare/CMS regulations and applicability in administering the Medicare Product; health care coding and payment systems (such as ICD-9, CPT, HCPCS, NDC).
- Strong knowledge of compliance related activities, legislative and regulatory activities, health insurance operations, and legal issues.
- Ability to collaborate as part of cross functional teams, to improve clinical programs, enhance processes and share clinical information.
The Clinical Pharmacist Consultant would have a Bachelor's degree in Pharmacy or Doctor of Pharmacy (PharmD) or related field and 3-5 years of experience in clinical acute care/hospital setting or equivalent combination of education and experience.Required Licenses, Certifications, Registration, Etc.
Pharmacy license. Successful completion of a pharmacy residency or advanced degree in health-related field preferred. Must be an active and unrestricted licensed pharmacist in state of practice.Work Environment
No unusual working conditions
Work primarily performed in an office environment
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com
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