Community Health Group
Job Details
Job Location Corporate Headquarters - Chula Vista, CA
Position Type Full Time
Salary Range $130639.58 - $160033.48 Salary
Description
POSITION SUMMARY
The focus of this position is three-fold: provide timely, appropriate, and cost-effective drug therapy for health plan members by reviewing prior authorization and medical necessity requests; works to meet CMS regulatory requirements for Medicare Part D; and supports and develops clinical initiatives to achieve HEDIS goals.
COMPLIANCE WITH REGULATIONS
Works closely with pharmacy staff and PBM to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D and Medi-Cal as well accreditation standards such as NCQA.
RESPONSIBILITIES Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria. Provide clinical guidance and support to the pharmacy benefit specialists. Work collaboratively with interdisciplinary care team in care coordination rounds to optimize patient health outcomes. Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews. With the team, develops and implements clinical criteria for the review of non-formulary or non-preferred medications and clinical edits to adjudicate claims and enhance drug utilization Assists in analyzing and researching pharmacy cost trends and clinical program opportunities in managing high-cost therapies. Perform medication therapy management telephonically. Work collaboratively with various departments developing clinical programs and monitoring quality standards related to HEDIS, Star Measures, and NCQA. Works to meet CMS regulatory requirements for Medicare Part D, including but not limited to compliance related to formulary administration, the Part D coverage determinations process, Medicare reporting, Medicare medication safety and overutilization monitoring, and fraud, waste and abuse activities. In accordance with the State, develop educational outreach to improve drug utilization and prescribing practices. Perform retrospective reviews to monitor for concurrent use and over/under prescribing of medications with potential abuse or misuse and implement strategies to combat the misuse of these medications. Takes a lead role in the implementation of new drug-related initiatives and the establishment of new clinical pharmacy services or initiatives as requested. Contributes to the team effort, maintains customer confidence, protects operations, and identifies potential quality issues by attending department meetings; giving and receiving feedback. Performs other duties and assignments as requested. Qualifications
EXPERIENCE/SKILLS
Must have a current and unrestricted California pharmacy license. PharmD degree Minimum 1 year in managed care pharmacy; 3 years in retail or PBM experience preferred Experience with Medi-Cal and Medicare preferred Full working knowledge of Microsoft program Knowledge of managed care principles, CPT, ICD-10, HCPCS coding, experience with medical review criteria preferred Ability to communicate effectively verbally and in writing Exceptional telephone and customer service skills Ability to establish effective working relationships with physicians and medical professionals Ability to organize work effectively, determine priorities, and work well independently Bilingual preferred PHYSICAL REQUIREMENTS
Prolonged periods of sitting at desk; intermittent standing, walking, bending, stooping, lifting 10 lb. or less Will be required to share on-call coverage May be required to work evenings and/or weekends and holidays May be necessary to work and attend meetings outside of facility or normal business hours
The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.
All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.
Job Location Corporate Headquarters - Chula Vista, CA
Position Type Full Time
Salary Range $130639.58 - $160033.48 Salary
Description
POSITION SUMMARY
The focus of this position is three-fold: provide timely, appropriate, and cost-effective drug therapy for health plan members by reviewing prior authorization and medical necessity requests; works to meet CMS regulatory requirements for Medicare Part D; and supports and develops clinical initiatives to achieve HEDIS goals.
COMPLIANCE WITH REGULATIONS
Works closely with pharmacy staff and PBM to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D and Medi-Cal as well accreditation standards such as NCQA.
RESPONSIBILITIES Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria. Provide clinical guidance and support to the pharmacy benefit specialists. Work collaboratively with interdisciplinary care team in care coordination rounds to optimize patient health outcomes. Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews. With the team, develops and implements clinical criteria for the review of non-formulary or non-preferred medications and clinical edits to adjudicate claims and enhance drug utilization Assists in analyzing and researching pharmacy cost trends and clinical program opportunities in managing high-cost therapies. Perform medication therapy management telephonically. Work collaboratively with various departments developing clinical programs and monitoring quality standards related to HEDIS, Star Measures, and NCQA. Works to meet CMS regulatory requirements for Medicare Part D, including but not limited to compliance related to formulary administration, the Part D coverage determinations process, Medicare reporting, Medicare medication safety and overutilization monitoring, and fraud, waste and abuse activities. In accordance with the State, develop educational outreach to improve drug utilization and prescribing practices. Perform retrospective reviews to monitor for concurrent use and over/under prescribing of medications with potential abuse or misuse and implement strategies to combat the misuse of these medications. Takes a lead role in the implementation of new drug-related initiatives and the establishment of new clinical pharmacy services or initiatives as requested. Contributes to the team effort, maintains customer confidence, protects operations, and identifies potential quality issues by attending department meetings; giving and receiving feedback. Performs other duties and assignments as requested. Qualifications
EXPERIENCE/SKILLS
Must have a current and unrestricted California pharmacy license. PharmD degree Minimum 1 year in managed care pharmacy; 3 years in retail or PBM experience preferred Experience with Medi-Cal and Medicare preferred Full working knowledge of Microsoft program Knowledge of managed care principles, CPT, ICD-10, HCPCS coding, experience with medical review criteria preferred Ability to communicate effectively verbally and in writing Exceptional telephone and customer service skills Ability to establish effective working relationships with physicians and medical professionals Ability to organize work effectively, determine priorities, and work well independently Bilingual preferred PHYSICAL REQUIREMENTS
Prolonged periods of sitting at desk; intermittent standing, walking, bending, stooping, lifting 10 lb. or less Will be required to share on-call coverage May be required to work evenings and/or weekends and holidays May be necessary to work and attend meetings outside of facility or normal business hours
The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.
All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.