Clinical Pharmacist

Overview

• Provide clinical expertise in reviewing prior authorization requests for drug products based on member benefits and coverage criteria.
• Collaborate with compliance committees to report utilization review statistics and ensure adherence to corporate standards.
• Summarize daily utilization review data and track compliance of review cases effectively.
• Offer clinical guidance and mentorship to pharmacy technicians to enhance operational efficiency.
• Utilize knowledge of drug coding systems and claims adjudication processes for accurate reviews.
• Support Pharmacy and Therapeutics Committee functions by reviewing guideline criteria for drug authorizations.
• Ensure quality control measures are met and identify opportunities for performance improvement.
• Conduct drug research to maintain up-to-date knowledge for application in authorization reviews.

Key Responsibilities & Duties

• Evaluate prior authorization requests and determine coverage based on established criteria.
• Prepare and present utilization review statistics to compliance committees.
• Analyze data to summarize daily review activities and compliance tracking.
• Provide clinical oversight and training to pharmacy technicians.
• Apply expertise in drug coding systems and adjudication processes for accurate reviews.
• Review and update guideline criteria for drug authorizations in alignment with pharmacy benefit design.
• Implement quality control measures and identify areas for operational improvement.
• Conduct research on drug information and disease states for informed decision-making.

Job Requirements

• Doctor of Pharmacy (PharmD) degree from an accredited institution.
• Minimum of 3 years of experience in clinical pharmacy or related field.
• Active pharmacy license in the applicable state.
• Proficiency in drug coding systems (NDC, GCN, GPI, USC) and NCPDP claims adjudication.
• Strong analytical skills for data summarization and compliance tracking.
• Ability to provide clinical guidance and support to pharmacy technicians.
• Knowledge of quality control measures and performance improvement strategies.
• Excellent research skills for maintaining drug knowledge and disease state understanding.