Job Profile Summary
Position Purpose: Define and develop standard and custom formularies for assigned plan.
Education/Experience: Bachelor’s degree or advanced degree (Pharm.D., M.S.) in pharmacy. 2 years of mail order, retail, hospital or managed care pharmacy experience or 1 years of pharmacy residency program experience.
Licenses/Certifications: Current state’s Pharmacist license with no restrictions.
Responsibilities
• Develop clinical criteria for medications, recommend plan design changes, and clinical programs to be initiated
• Monitor prior authorization requests
• Provide clinical support to internal departments and address clinical related questions
• Ensure appropriate quality controls and initiates opportunities for performance improvement in pharmacy/practice
• Develop and implement programs designed to impact DUR for both Medicaid and Medicare
• Develop, implement, and maintain policies and procedures for the pharmacy department
• Participate in the coordination of the Medicare MTM program
• Assist case management team with members including clinical rounds presentations
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
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Summary:The main function of a pharmacist is to dispense prescription medications to patients and offer expertise in the safe use of prescriptions. They also may conduct health and wellness screenings, provide immunizations, oversee the medications given to patients, and provide advice on healthy lifestyles.Responsibilities: Prepares medications by reviewing and interpreting physician orders; detecting therapeutic incompatibilities. Dispenses medications by compounding, packaging, and labeling pharmaceuticals. Controls medications by monitoring drug therapies; advising interventions. Completes pharmacy operational requirements by organizing and directing technicians' work flow; verifying their preparation and labeling of pharmaceuticals; verifying order entries, charges, and inspections. Provides pharmacological information by answering questions and requests of health care professionals; counseling patients on drug therapies. Develops hospital staff's pharmacological knowledge by participating in clinical programs; training pharmacy staff, students, interns, externs, residents, and health care professionals. Complies with state and federal drug laws as regulated by the state board of pharmacy, the drug enforcement administration, and the food and drug administration by monitoring nursing unit inspections; maintaining records for controlled substances; removing outdated and damaged drugs from the pharmacy inventory; supervising the work results of support personnel; maintaining current registration; studying existing and new legislation; anticipating legislation; advising management on needed actions. Protects patients and technicians by adhering to infection-control protocols. Maintains safe and clean working environment by complying with procedures, rules, and regulations. Maintains pharmacological knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies. Contributes to team effort by accomplishing related results as needed.Qualifications: Doctor of Pharmacy (PharmD) or Bachelor of Science Pharmacy degree Current pharmacist license in good standing with the State Board of Pharmacy in the State where the position is located (Florida, New Mexico or Texas). If license is not in state where the position is located, must be able to obtain this licensure within 6 months Must have current Pharmacist licensure or obtain Pharmacist licensure in the required states and any future required states. Currently, the following states are required: Alabama, Arkansas, Idaho (Registration in lieu of licensure), Kentucky, Louisiana, Maryland, Michigan, Mississippi, Nebraska, and Oklahoma, Oregon, Tennessee and West Virginia 0-2 years of experience as a Pharmacist
Story Behind the Need – Business Group & Key Projects - Health plan or business unit
- Team culture
- Surrounding team & key projects
- Purpose of this team
- Reason for the request
- Motivators for this need
- Any additional upcoming hiring needs?
- Pharmacy Appeals Department – Dept 247
- Inclusive team culture, learning environment (not punitive)
- Pharmacy Ops Dept includes PA and Appeals – no key projects
- Evaluate redetermination and appeals coverage requests
- Department growth
- Increased volume
- n/a
Typical Day in the Role - Daily schedule & OT expectations
- Typical task breakdown and rhythm
- Interaction level with team
- Work environment description
• Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician’s recommended denial, suggested formulary alternatives, comments and attachments for appropriateness.
• Verifies member’s ID number and date of birth.
• Verifies member’s eligibility in the appropriate health plan eligibility system.
• Records carrier and group number if applicable.
• Checks for previous prior authorization decisions.
• Verifies coverage in member’s prescription benefit when necessary.
• Verifies coverage in member’s health plan benefit when necessary.
• Evaluates prescription claim history.
• Reviews chart notes and/or lab values.
• Identifies provider specialty when appropriate.
• Applies Medical Policy Criteria to prior authorization requests.
• Evaluates whether request meets criteria for approval.
• Reviews the request using professional clinical judgment on a case by case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.
• Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool
• Communicates with physicians regarding prior authorization:
o For a non-formulary drug
o Plan benefits, exclusions
o Quantity limits
o Age restrictions
o Formulary alternatives
• Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department)
• Compiles data for reporting purposes:
o Drug utilization of non-formulary drugs
o Overturned IPS recommended denials
o Audit pharmacy claims greater than $200.00
o Suggest addition or deletion of drugs to/from the formulary
o Updating qty/days or age limit ends
o Support National P&T Committee
o Other tasks which may arise during the performance of any of the above mentioned duties
Compelling Story & Candidate Value Proposition - What makes this role interesting?
- Points about team culture
- Competitive market comparison
- Unique selling points
- Value added or experience gained
Candidate Requirements Education/Certification Required: Pharm D. Preferred: n/a
Licensure Required: Any US state Preferred: n/a
- Years of experience required
- Disqualifiers
- Best vs. average
- Performance indicators
Ideal candidates are:
Self-motivated
Metric driven (retail experience can be an indicator of this but not always)
---what are the metric goals in their current role? How many cases per day do they complete?
---this is crucial information if they are working in a prior auth role or have worked prior auth before
Easily adaptable to frequent change
Any previous Centene experience or experience with our systems (MHK, Client, Micromedex, AHFS to name a few)
Minimal gaps in employment history
Licensure in the following states COULD be a plus – NC, IN, WA, NH, GA
Must haves: At least one year of professional RPh experience
Nice to haves: Some experience working in managed care, understanding of Medicare/Medicaid law
Disqualifiers: n/a
Performance indicators: • Sign 85 – 100 cases daily
- Top 3 must-have hard skills
- Level of experience with each
- Stack-ranked by importance
- Candidate Review & Selection
1 Self-Motivated/Good Time Management Skills 2 Working Knowledge of Office Suite 3 Goal Oriented
Candidate Review & Selection - Shortlisting process
- Second touchpoint for feedback
- Interview Information
- Onboard Process and Expectations
Projected HM Candidate Review Date: ASAP Number and Type of Interviews: 1 Extra Interview Prep for Candidate: NA Required Testing or Assessment (by Vendor): NA
