Clinical Programs Pharmacist

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

What You Will Be Doing:

Under general supervision, the Clinical Programs Pharmacist is responsible for assisting in the planning and development of Medi-Cal and Medicare pharmaceutical utilization strategies, medication therapy management, and streamlining care processes in a manner that results in high quality, cost-effective health care for Health Plan members. The work is multifaceted and challenging, requiring a strong level of independence and careful judgment.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

Essential Functions:

• Conducts daily Paid Claims review to ensure that claims adjudicate appropriately based on the Part D benefit.
• Conducts daily rejected claims reviews and ensures issues identified are corrected or properly escalated.
• Ensures all Prescription Drug Event (PDE) rejections are reviewed, corrected and re-submitted appropriately.
• Reviews PBM's drug utilization review (DUR) reports and designs quality initiatives as needed.
• Collaborates with other departments (Utilization Management (UM), Case Management, Health Education, Quality Improvement, Health Equity) to ensure allignment with quality of care programs.
• Reviews Part B prior authorization requests and coordinates with the UM department.
• Attends annual Part D benefit training and is able to answer questions about medication coverage from inside and outside the department.
• Supports the identification, development and implementation of Health Plan's care management initiatives (e.g. Medicare STARS programs, pharmacy adherence programs): compiles and analyzes Medicare medical and pharmacy data; identifies related member populations; recommends and develops appropriate interventions; monitors and takes action on results.
• Maintains the online Medicare formulary to ensure accurate and up-to-date information is posted.
• Conducts clinical review of pharmacy prior authorizations; makes clinical determinations and offers therapeutic alternatives, if applicable, according to Health Plan's review criteria.
• Assists the Pharmacy and Therapeutics Committee and the Clinical Operations Committee in the development, maintenance and evaluation of the Health Plan's physician administered drug benefit for Medi-Cal and Medicare Part B, clinically effective and cost-effective pharmacy management strategies, including but not limited to appropriate utilization management restrictions.
• Promotes clinically appropriate prescribing practices through targeted education programs which conform to national practice guidelines.
• Represents Health Plan in a manner that promotes a positive image of Health Plan in the community.
• Promotes an environment that supports and encourages the adoption of Health Plan's stated values.

Non-Essential Functions

• Other duties as required.
• Supervises and teaches pharmacy students enrolled in Health Plan's clerkship program.

What You Have:

Education and Experience

Required

• Graduate of a College of Pharmacy.

Preferred

• Doctor of Pharmacy or other advanced degree from an accredited college or university.
• Completion of managed care pharmacy or clinical residency.
• Experience in a managed care pharmacy department.
• Significant knowledge and expertise in managed care pharmacy, medication therapy management, and evidence-based medicine in the areas appropriate for clinical assignments.

Licenses, Certifications

Required

• California State Board of Pharmacy registered pharmacist.

Preferred

• None.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• Ability to work independently.
• Ability to commit to and facilitate an atmosphere of collaboration and teamwork.
• Optimizes work processes: Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Strong oral and written communication skills, with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of Health Plan.
• Nimble learning: Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Resiliency: Rebounds from setbacks and adversity when facing difficult situations.
• Interpersonal savvy: Relates openly and comfortably with diverse groups of people; interacts effectively with individuals both inside and outside of Health Plan; establishes and maintains effective working relationships.
• Strong leadership skills with the ability to establish direction, build alliances, inspire, and motivate others.
• Expert knowledge of and skills in clinical and distribution principles and techniques.
• Ability to identify, develop, and monitor medical and pharmacy utilization management activities.
• Produces work that is accurate and complete.
• Produces the appropriate volume of work.
• Demonstrates alignment with Health Plan's strategy, vision, mission and values.
• Time management: Uses time effectively and efficiently; values time; concentrates his/her efforts on the more important priorities; can attend to a broader range of activities; meets deadlines. Strong customer service skills.
• Strong facilitation, problem solving, and conflict resolution skills.
• Ability to handle confidential information with appropriate discretion.

Preferred

• Expert knowledge of The Centers for Medicare & Medicaid Services (CMS) Pharmacy Manual.
• Expert knowledge of the principles and practices of managed care.
• Expert knowledge of state-sponsored health care programs, including Medi-Cal.
• In-depth knowledge of HEDIS as related to pharmaceutical use.
• In-depth knowledge of disease management with ability to plan, implement and carry on programs using the principles of risk stratification, member education, provider education, incentives, reports and predictive modeling.
• Expert knowledge of and ability to identify, implement, monitor and analyze relevant pharmacy metrics models, and implement effective interventions based on results.
• Strong assessment and analytical skills, including the ability to synthesize, distill concepts, draw conclusions, and identify implications.
• Strong report writing skills with proficiency in using Microsoft Excel and other report writers.

What You Will Get:

HPSJ Perks:

• Competitive salary
• Robust and affordable health/dental/vision with choices in providers
• Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee's birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven - our members and community are at the core of everything we do.
• A shorter commute - if you're commuting from the Central Valley to the Bay Area.
• Visibility and variety - you have a chance to work with people at all levels of the organization, and work on diverse projects.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.

Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.