The Clinical Pharmacist is responsible for oversight and management of all day-to-day aspects of the Pharmacy Services Department, including but not limited to issuance of all pharmacy coverage decisions, development of policies and procedures and coordination of pharmacy benefits for members. Principal responsibility for maintaining compliance with all state and federal legislation. Coordinate formulary design and implementation to ensure cost-effective utilization and promote evidence based healthcare. In addition, responsibility includes maintaining contact with other department heads, medical staff, and nursing staff to deal with all clinical, administrative, financial & regulatory challenges impacting pharmacy services. Serve as a clinical resource person for Health Services staff, other internal associates and external vendors as necessary.
Assist Director of Medical and Pharmacy Services - in providing direction to pharmacy services, including successful development, implementation, and communication of pharmacy services programs.
Primary responsibility for drug authorizations reviews, including specialty pharmacy.
Assist Pharmacy Director with the development and maintenance of policies and procedures pertaining to the pharmacy program.
Monitor departmental goals, objectives and project planning as established by Director of Medical and Pharmacy Services. Maintain an active role in meetings and strategic planning process as they pertain to pharmacy services.
Ensure that pharmacy services consistently delivers best practice results in a timely manner.
Work with Director of Medical and Pharmacy Services to implement process improvements and internal controls to ensure that pharmacy services personnel operate efficiently.
Monitor pharmacy-related performance metrics to evaluate the effectiveness of existing programs and identify and resolve department inefficiencies.
Utilize appropriate data resources to evaluate and improve member and provider satisfaction with the pharmacy services helpdesk.
Assist Director of Medical and Pharmacy Services to design and implement solutions to maintain compliance with federal and state regulations.
Primary liaison to participating providers and other contracted entities on clinical pharmacy initiatives.
Actively participate in discussion and develop clinical presentations to the QAUMPT Committee.
Ensure that pharmacy services personnel are a valuable resource to Marketing & Sales, Billing and Enrollment, Underwriting, Case Management and Provider Relations departments.
Provide clinical resources to medical review team and other plan staff as needed.
Participate in pharmacy counseling opportunities with members in the community.
Consult with medical personnel in the community regarding company policies and procedures as they relate to clinical decision making.
Assist Director of Medical and Pharmacy Services with drug formulary design and development, implementation and risk management in a manner that will improve quality, control utilization, and contain costs. Assist Director of Medical and Pharmacy Services with Formulary development, prior authorization criteria and benefit structure for all government lines of business.
Assist in the design and implementation of innovative pharmacy benefits, including but not limited to Medication Therapy Management, Medication Adherence Improvement Projects, and Oncology Management Strategies.
Assist Director of Medical and Pharmacy Services with the development of all internal and external pharmacy-related educational documentation.
Ensure that all pharmacy benefits are administered according to plan direction.
As directed, assist marketing and sales teams with member and broker education on pharmacy benefits.
Perform other duties as assigned.
Act as backup for other team members and departmental functions.
Work with Director of Medical and Pharmacy Services and/or designee to improve processes, systems, reporting, and services provided by the department
Represent Pharmacy Services Department, both internally and externally, as requested.
Assist with other duties or functions that may be required for the efficient and effective functioning of the department or PacificSource.
Relationships: Establish and maintain relationships with community services and providers. Maintain a positive working environment with other PacificSource internal staff to assure effective collaboration. Provide leadership and support to designated Pharmacy Services Department staff and teams. Collaborate with all PacificSource departments and employees. Work with providers, healthcare facilities, vendors, community services, members/patients, and other elements of the medical community.
Work Experience: Recent Pharmacy graduate considered. Experience in retail or institutional pharmacy preferred. Prior success in healthcare integration, process development and program implementation is desirable. Additional experience managing complex work processes is highly preferred. Knowledge of diagnoses and procedures codes, including ICD-9, DSM-IV, and CPT Codes.
Language skills: Accurately documents case notes and letters of explanation which may become part of legal records. Excellent communication and negotiation skills, both verbal and written.
Mathematical Skills: Basic math skills required, including percentages, ratios, graphing and spreadsheet skills.
Reasoning Ability: Thorough knowledge and comprehension of pharmaceutical services, including all federal and state statutes and regulations as they pertain to the insurance-related pharmacy services and benefits administration. Ability to assess pharmaceutical alternatives, treatment plans, drug technologies and new approaches to delivering pharmacy services. . Ability to work independently with minimal supervision.
Education, Certificates, Licenses, Registration: Bachelor of Science in Pharmacy and/or Doctor of Pharmacy degree and Idaho license.
Other Skills and Abilities: Ability to deal with members, patients and families at all levels of care and/or crisis. Ability to use computerized systems for data recording and retrieval. Continually seek to improve quality of service, care, and processes for internal and external customers. Assure patient confidentiality, privacy, and health records security. Accurately interpret contractual benefits. Provide compassionate and confidential service to members/patients. Support policy and change process, both internal and with providers. Identify and inform Director of Medical and Pharmacy Services of high exposure cases and/or potential reinsurance claims. Accountable for service to internal and external customers. Knowledge of health insurance and State of Oregon mandated benefits required. Thorough understanding of national drug database, pharmacy benefit configuration, and medication pricing. Thorough understanding of Evidence Based Medicine and primary literature resources. Ability to critically evaluate medical literature. Proficient Computer Skills in a Windows Operating System Environment.
Works inside in a general office setting with ergonomically configured equipment and some outside service calls or visits to healthcare environments.
Mental / Physical Requirements:
Requires sitting, standing, walking, stooping and bending according to work tasks. Light lifting and carrying of files and department notebooks. Must be able to read text and numbers and communicate clearly and distinctly using a voice telephone and in person. Handles files, computer keyboard, and writing instruments.
This job description indicates the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.
PacificSource is an equal opportunity and affirmative action employer.
PacificSource Health Plans is anything but a typical health plan. We’re a growing, independent, not-for-profit organization with a...