Description

JOB SUMMARY

This job works in a team oriented environment monitoring FDA-approvals, drug manufacturer pipelines, and assess drug utilization reports, in order to develop and execute the the Organization's Drug Formulary, and / or recommend codes for pharmaceutical based reporting. The incumbent may write drug monographs for Committee review; develops and implements the Organization's management programs including but not limited to : prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling, pharmacy policy review and development and / or review of member specific information to improve individual outcomes as an adjunct to health coaching. If acting in the capacity as a clinical pharmacist the incumbent may also review UM requests; provide consultation into the case and disease management identification process, and consult with the Organization's Associate Medical Directors and Medical Directors when appropriate, follow-up on appeals in accordance with our regulatory guidelines. The incumbent develops and implements physician, pharmacy, account, and member educational initiatives that promote the Organization’s Formularies, utilization management programs, and case / disease management initiatives; providing clinical review and decisions for physician and member appeals and participates on cross-functional committees to develop and implement clinical and operational initiatives.

ESSENTIAL RESPONSIBILITIES

• Monitor FDA-approvals, drug manufacturer pipelines, assess drug utilization reports, and write drug monographs for Committee review to develop the Organization's Drug formulary and / OR provide recommendations for NDC code capture, and monthly identification of high risk members.
• Gateway - Assist in the development of Gateway’s Drug Formularies by monitoring FDA-approvals and drug manufacturer pipelines, assessing drug utilization reports, and writing drug monographs for Pharmacy & Therapeutics Committee review.
• Assist in the development and implementation of utilization management programs including but not limited to : prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling medical policy review and development, member facing outreach initiatives
• Develop and implement physician, pharmacy, account, and member educational initiatives that promote the Organization's Formularies, utilization management programs, and disease management initiatives.
• Provide clinical review and decisions including but not limited to : physician and member appeals, member or provider information / education.
• Participate on cross-functional committees to develop and implement clinical and operational initiatives within Integrated Clinical Services. May participate in outreach efforts as needed to effectively reach goals of Medication Therapy Management programs to include, but not limited to Comprehensive Medication Reviews and Targeted Medication Reviews.
• Identify and assist in managing department process improvements to maximize overall efficiencies.
• Manage individual projects for timely review with the Director, Clinical Pharmacy.
• Participate in Medicare Stars performance measures to drive contribution to excellence (5 Stars).
• Other duties as assigned or requested.

QUALIFICATIONS

Required

Preferred

SKILLS

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products / services (sales employees)

Never

Physical work site required

Lifting : up to 10 pounds

Constantly

Lifting : 10 to 25 pounds

Occasionally

Lifting : 25 to 50 pounds

Rarely

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation / gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation / gender identity, protected veteran status or disability.

EEO is The Law

Equal Opportunity Employer Minorities / Women / Protected Veterans / Disabled / Sexual Orientation / Gender Identity ()

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.

For accommodation requests, please contact HR Services Online at