- Full Time/Contract
- Rancho Cucamonga, CA
Rancho Cucamonga, Ca
Under the direction of the Manger, Pharmacy Program, the Clinical Pharmacist is responsible to review prior authorizations, provide clinical recommendations to Providers, and provide clinical education and guidance to the pharmacy team.
- Review medication prior authorizations requests according to established treatment protocols, clinical medication criteria, clinical practice guidelines and monographs.
- Decision prior authorizations 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.
- Ensue all departmental goals (including, but not limited to turnaround, production expectations and quality metrics) are met.
- 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).
- Communicate the medication prior authorization clinical decision with Providers.
- Assist in providing clinical information, recommending formulary alternatives and educating on pharmacy benefits to Providers, Members and to Pharmacy Program Specialist team members.
- Provide open lines of communication with Pharmacy Providers on issues related to IEHP formulary or pharmacy policy and procedures.
- Research clinical information to maintain drug and disease state knowledge for application to prior authorization reviews and appeal cases. Attend seminars to learn about different disease states and respective medication therapy management.
- Provide clinical education, guidance and support to Pharmacy Program Specialist team members to review prior authorizations and ensure adherence to standard work.
- Provide monthly clinical disease state and/or drug category education to Pharmacy Program Specialist team members.
- Develop guidelines, processes, and standard work to assist Pharmacy Program Specialist team members process prior authorizations accurately and efficiently.
Coordinate prior authorization and drug utilization reviews to ensure regulatory reporting requirements and fraud and abuse reporting are met.
- Make recommendation(s) for addition, changes and/or deletions to the IEHP's medication formulary.
- Actively participate in quality improvement process enhancements, LEAN projects and manage for daily improvement (MDI) visual management.
- Participate in multi-disciplinary team (Primary Care Provider, Case Manager, UM Nurse, etc.) to discuss the ongoing needs of IEHP 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.
- Demonstrate ability to maintain productive working relationships with team members, other internal and external Providers, and management team
- Provide clinical support to the prior authorization team for claims review.
- Review pharmacy related appeals and work with Medical Directors on decision making. Attend monthly appeals meeting and discussions as part of interdisciplinary team with medical directors.
- 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
- Perform peer review auditing and quality assurance checks to ensure clinical decision making meets the regulatory and company standards. Participate in weekly case review discussions to review quality assurance findings.
- Participate in Medical Services appeals meetings, or other activities as needed.
- Provide mentorship and leadership training to Pharmacy Program Specialist team members.
- Minimum of 1-year Managed Care residency.
- Or 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.
- Clinical residency preferred.
- Preferable experience in an HMO or Managed Care setting.
- 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.
- Driver's License Required
- Communication (Written and Verbal)
- Compliance with Healthcare Regulations
- Computer (Microsoft Office)
- Customer Service
- Knowledge of HIPPA
- Medicaid and Medicare Management
- Medical Coding and Billing
- Commitment to Team Culture
$47.41 – 60.47
Pay rate will commensurate with experience
Temporary position 6 months
Monday – Friday 8:00 am – 5:00 pm