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This position is responsible for maintaining and supporting the Medicare and/or Medicaid formulary and providing clinical and economic data necessary to make formulary decisions. This position acts as a pharmacy resource for network physicians, health plan members, medical services, care management, and member service staffs as well as other internal partners. Assists in performing all CMS mandated quality and compliance activities. Serves as a pharmacy topic educator and training resource to Medicare and/or Medicaid health plan departments and personnel. This position has the latitude for independent decision-making within the limits of acceptable standards of pharmacy practice and state and federal laws. This position requires interactions at all levels of staff and management. External interactions include network physicians, and health plan members, etc.
Job Responsibility
Provides and assists with the management of pharmacy services to Medicare and/or Medicaid health plan members that is consistent with acceptable standards of pharmacy practice and applicable regulations and guidance
Assists in defining, implementing and managing Medicare and/or Medicaid health plan pharmacy programs including the medication therapy and drug utilization management
Directly interfaces with Medicare and/or Medicaid members, and network providers concerning pharmacy issues and programs
Designs and delivers staff/community educational programs and provides individual medication counseling, if appropriate
Produces pharmacy utilization reports as well as clinical and economic data to the health plan to assist in pharmacy benefit utilization analysis
Conducts audits and produces reports that can be utilized by the care management, quality and compliance departments to evidence quality pharmacy services and meets Medicare and/or Medicaid requirements
Applies the principles of continuous quality improvement consistent with job expectations
Incorporates quality improvement principles into other activities and projects (i.e. data collection, documentation)
Develops criteria for drug use evaluations, medication use indicators and disease-based evaluations
May be assigned to create data extracts of the pharmacy claims system and support ad hoc report requirements for health plan pharmacy utilization management and audit functions
Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards
Provides all customers with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day
Perform other duties as required
Requirements
5 years or more as a practicing pharmacist
3 years of experience in the managed care pharmacy field
2 years of direct prior authorization experience
2 years of managed care/health plan and/or pharmacy benefits experience
Doctor of Pharmacy (Pharm.D) degree
Active, current and unrestricted State of Arizona pharmacist license