Under the direction of the Pharmacy Benefit Manager, this pharmacist is responsible for supporting the development and administration of the pharmacy drug benefits as it applies to formulary maintenance, benefit coverage and medical neccesity decisions and implementation of new pharmacy benefit programs. Essential Responsibilities:Implements formulary decisions made by the Pharmacy and Therapeutics Committee (P&T) from Commercial and Medicaid lines of business. Maintains Kaiser Mid-Atlantic Stat... more details
Description:
Job Summary:
Under the direction of the Pharmacy Benefit Manager, this pharmacist is responsible for supporting the development and administration of the pharmacy drug benefits as it applies to formulary maintenance, benefit coverage and medical neccesity decisions and implementation of new pharmacy benefit programs.
Essential Responsibilities:
Implements formulary decisions made by the Pharmacy and Therapeutics Committee (P&T) from Commercial and Medicaid lines of business. Maintains Kaiser Mid-Atlantic States formularies and drug lists at contracted Pharmacy Benefit Managers (PBMs) via the POINT database. Ensures formulary and drug list consistency through all contracted PBMs. Maintains formulary and drug lists documents posted on various websites.
Reviews and evaluates medication requests regarding benefit coverage and medical neccesity to determine if an approval can be granted or a denial can be recommended. (Urgent requests will require on call or after hours coverage). Develops and maintains clinical criteria for prior authorization guidelines. Participates in the Pharmacy and Therapeutics Committee (P&T) as needed. Assists in ensuring compliance with all UM standards and reporting as pertains to PBM delegated activities.
Actively participate in interregional pharmacy benefits workgroups related to specific drug benefit specialties, such as Commercial Benefits, Medicare Part D, and Self Funding.
Ensures compliances with State and Federal laws. Creates, updates, and maintains Policies and Procedures relating to Formulary, Medicare, Medicaid, and Pharmacy Benefits Managers (PBMs).
Supports and provides drug knowledge and drug utilization review to Pharmacy Benefits Team. Serves as a subject matter expert for the drug benefits and relevant pharmacy administered medical benefits. Responds to inquiries on benefit questions and authorization requests from multiple stakeholders.
Keeps up to date on new FDA approved medications and/or indications, pharmacy drug benefit designs and regulatory changes impacted pharmacy benefits or UM standards.
Performs other duties as directed.
Basic Qualifications:
Experience
Minimum two (2) years of experience as a pharmacist with specialized experience in pharmacy benefits OR
Completion of a PGY1 or PGY2 residency program.
Minimum two (2) years of experience with Microsoft Word, Excel and PowerPoint.
Education
Bachelors degree in pharmacy or Pharm D required.
License, Certification, Registration
Pharmacist License (Virginia)
Additional Requirements:
Exceptional interpersonal, verbal, presentation and written communication skills.
Preferred Qualifications:
Minimum two (2) years of experience with formulary management, knowledge of Medicare and Medicaid regulations and compliance, and work with Pharmacy Benefit Managers.
Minimum one (1) year of experience with Microsoft Access.
Masters degree in business administration, health science administration, or six (6) years of experience in a directly related field.
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