You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: Define and develop standard and custom formularies for complex or specialized medications for assigned plan
- Develop clinical criteria for review of complex or specialized medications, recommend plan design changes and communicate recommendations to clients
- Monitor and review prior authorization requests for complex or specialized medications
- Develop and design clinical edits to adjudicate claims and enhance drug utilization
- Analyze pharmacy cost of care, trends, and coordinate the development of appropriate use protocols and guidelines
- Set criteria for medication analysis, coordinate reports to clients, meet regulatory reporting requirements for drug utilization review and fraud and abuse reporting
- Develop and implement medication therapy management programs. Evaluate program performance, recommend changes and ensure successful implementation of changes
- Ensure and evaluate quality controls and implement opportunities for performance improvement
- Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
- Provide clinical guidance and support to various departments and address clinical related questions
- Define, develop, implement and maintain standard and custom formularies and/or clinical edits and implement and maintain regulator required formularies and/or clinical edits, as required by your manager
- Provide formulary and/or clinical edit subject matter expertise, guidance and support to Formulary and Benefit Management team, various departments and plan pharmacy departments
For Clinical Programs (Operational Excellence):- Support ongoing evaluation of clinical program initiatives promoting quality, safety and cost of care opportunity
- Support oversight, development and expansion of clinical pharmacy programs and initiatives by assessing utilization trends and relevant data and literature
- Analyze pharmacy data and trends needed to drive positive member outcomes
- Ensure and develop strategic relationships supporting organizational strategic initiatives
Education/Experience: Bachelor’s degree or advanced degree (Pharm.D., M.S.) in pharmacy. 4+ years of mail order, retail, hospital, managed care pharmacy experience or pharmacy residency program experience.
Licenses/Certifications: Current state’s Pharmacist license with no restrictions
May be required to obtain additional state licensure based on business needs
Pay Range: $103,500.00 - $191,600.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
