Facilitates the company's efforts in the development of medical pharmacy solutions programs. Supports drug utilization review (DUR) efforts by reviewing physician prescribing patterns, consulting with physicians regarding these patterns using evidence-based best practices, working closely with internal staff in the refinement of the company's medical pharmacy management solutions programs, providing consultation on pharmacy issues to clinical operations representatives and facilitating the successful implementation of these programs for customer organizations. Primary activities center on discussions with practicing physicians (and other prescribers) to consult on prescribing of specialty medications. Coordinates with operations, clinical, medical, reporting and other internal departments as needed.
Pharmacy Data Review: Regularly reviews and monitors prescription claims data and prescribing practices identified as outliers by internal and/or external analysis of pharmacy claims data.
Telephonic Consultations/Interventions: Contacts physicians and prescribers identified as needing consultation to provide coaching on prescribing practices that have been identified as outliers. Reviews prior authorizations and determine opportunities for interventions.
Intervention Tracking and Documentation: Tracks contact attempts and contacts per operations procedures. Documents content of and results of consultations as defined in operations procedures; maintains records as required.
Intervention Refinements: Collaborates on the refinement of consultation scripting; solicits and utilizes input from those contacted toward scripting improvements.
Operations: Contributes to the success of the operations of the pharmacy program by assisting with the implementation and management of both written and verbal communications to physicians and prescribers and maintenance of the edits and data elements that support the edits. Is available for consultation on pharmacy-related questions and issues for others within the organization (e.g. health coaches, care managers, etc.). Updates and maintains program engine, coding, consultation sheets and outreach program as needed.
Quality Improvement: Contributes to program improvements by using continuous quality improvement processes, by being proactive in identifying improvement opportunities and by contributing on-going consultation and collaboration with product leaders.
Medical/Clinical: Upholds clinical integrity of pharmaceutical solutions by staying up-to-date on medication information, contributing to the identification of pharmacy program best practices, collaborating with Medical Directors, Medical Dept, and Clinical Dept and provides pharmacy expertise within the organization.
Managerial Support : Supports system User Acceptance Testing (UAT), performs monthly call audits to measure and report quality, researches and resolves escalated issues, and maintains and monitors clinical workloads to ensure performance goals are achieved.
Coaching/Training: Provides support and coaching to Initial Clinical Review (ICR) Pharmacists and other clinical team members in the course of normal operations. Identifies team member training needs and provides real time coaching/training. Act as a mentor to other ICR Pharmacists and other clinical team members.
Contributes creative solutions to improve operational efficiency and effectiveness of pharmacy team.
Other Job Requirements
Responsibilities
7+ years' experience in clinical pharmacy with emphasis in specialty pharmacy, oncology or other clinical pharmacy area. Managed care pharmaceutical service experience plus experience with coaching physicians and prescribers on medication issues, especially on specialty medications.Knowledge of current research related to specialty medications.-Strong research and implementation skills in practical settings.Analytic skills which can translate into practical and pragmatic recommendations.Strong team orientation with respect for all members.Strong verbal and written communications skills.People skills are essential that allow for the successful consultation with physicians, prescribers and pharmacists and for successful collaboration with company employees and external vendors who do not directly report to this job.Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems.For positions supporting Medicare Part B, 5+ years of PBM experience required, 2+ years of Medicare Part B experience required and 2+ years of audit experience required.
General Job Information
Title
Lead Clinical Pharmacist Reviewer MediCal
Grade
30
Work Experience - Required
Pharmacy
Work Experience - Preferred
Education - Required
Bachelors - Pharmacy
Education - Preferred
PharmD - Pharmacy
License and Certifications - Required
RPH - Registered Pharmacist - Pharmacy
License and Certifications - Preferred
PharmD - Doctor Of Pharmacy, State Licensure - Pharmacy
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Magellan is the employer of choice for hard working people interested in making a difference in the health care industry and in the communities where we work and live. Our strong culture of caring is the common thread in both our business strategy and our work environment. We value professional growth and development, total health and wellness, rewards and recognition as well as employee unity. Magellan is a place where you can thrive.
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