Managed Care Clinical Pharmacist - Harris Health System

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

* Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

* Childrens Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

* Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

* Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

JOB SUMMARY:JOB SUMMARY:

The Clinical Pharmacist provides highly specialized integrated clinical pharmacy services to the health plan. The Pharmacist will provide drug utilization reviews based on establish protocols for prior authorization and appeal requests, and to provide educational outreach to prescribers as appropriate.

• The Managed Care Clinical Pharmacist will assist with:
• Developing prior authorization review criteria for medications covered on pharmacy and medical benefits
• Conduct oversight over prior authorization criteria and delegated utilization management functions performed by PBM
• Reviewing PBMs formularies to identify improvement opportunities
• Create and refine policies and standard operating procedures for pharmacy operation processes
• Analyze claim data to identify drug utilization trends and cost-savings opportunities
• The Pharmacist may be responsible for other functions as assigned to ensure quality care for members while meeting expectations for prescription drug cost containment; and assisting with the development of clinical initiatives that support the processes of prior authorization, plan designs, formulary management, provider/member communication, retrospective drug utilization review and clinical consultation with members and providers.

MINIMUM QUALIFICATIONS:

• Education/Specialized Training/Licensure:
• Doctor of Pharmacy degree preferred.
• Bachelor degree in Pharmacy accepted.
• Active license as a pharmacist in Texas required; or will have Texas pharmacist license prior to start date.
• Work Experience (Years and Area): 2 year of applicable managed care pharmacy experience as a registered pharmacist; or 0-1 year of relevant pharmacy experience and completion of advanced training (i.e., completion of PGY1 managed care pharmacy residency, master or doctorate degree in a quantitative discipline such as finance, accounting, business administration, or informatics)
• Strong experience with prior authorization management preferred
• Medicare, Medicaid, and Marketplace experience with a Health Plan or PBM preferred
• Experience with advanced Excel required. Experience with SQL preferred.
• Software Operated: Microsoft Office (Word, Excel, Outlook)

SPECIAL REQUIREMENTS:

• Communication Skills: Above Average Verbal (Heavy Public Contact)
• Exceptional Verbal (e.g., Public Speaking)
• Writing /Composing (Correspondence / Reports )
• Other Skills: Analytical, Mathematics, Medical Terminology, MS Word, MS Excel
• Advanced Education: Advanced Training: Completion of PGY1 managed care pharmacy residency preferred, Bachelors Degree: Bachelor degree in Pharmacy from an accredited school of pharmacy accepted, Masters Degree: Master or doctorate degree in a quantitative discipline such as finance, accounting, business administration, or informatics preferred
• Doctorate : Pharm.D. degree preferred, Pharm.D. degree is required if candidate does not have a bachelor degree in Pharmacy

Work Schedule: Flexible Hybrid schedule.

RESPONSIBLE TO: Director
EMPLOYEE SUPERVISED: None