Decton Staffing Services
The position is an integral part of the Pharmacy Management team and will work to drive pharmacy initiatives and clinical programs within the Medi-Cal, Medi-Cal Whole-Child Model, Medicare and Elderly care lines of business. The incumbent will research, develop, and update drug utilization management strategies and work to promote clinically appropriate prescribing practices which adhere to the company’s formulary, regulatory guidelines, and national clinical practice guidelines; the position will interact frequently and independently with Plan members, prescribers, pharmacies, collaborative care team members, and with the PBM. General duties will include participation in clinical programs, development of drug utilization criteria, review of prior authorizations and appeals, interface with Plan members and prescribers to discuss drug therapy and perform other projects and reports as assigned.
- Generate and analyze claims and utilization reports to track general trends in drug utilization and to identify potential targeted utilization management activities.
- Develop and update drug utilization criteria.
- Proactively develop and maintain contacts and relationships with providers key to successful interaction and intervention activities.
- Participate in medication review, disease state management, and other clinical quality improvement programs such as Medication Therapy Management (MTM), Transitions of Care (TOC), interdisciplinary care teams and PACE.
- Assist the Pharmacy Director and the Manager of Clinical Pharmacists in the preparation of drug monographs and utilization reports for the Pharmacy & Therapeutics Committee.
- Utilize clinical and regulatory guidelines in the review of drug prior authorization and appeals requests.
- Adhere to regulatory compliance and quality guidelines as well as company policies and procedures.
- Update company Pharmacy policies and develops new policies and procedures when needed.
- Work with management to recommend, develop and implement target drug utilization intervention programs and other DUR/DUE activities.
- Work together with the Manager of Clinical Pharmacists and within Medical Management (e.g., with data manager, case managers, etc.) on various data integration and disease management and outcomes projects.
- Review members’ medication profiles and make recommendations to health care providers based on evidence-based medicine and national guidelines for disease management as part of the company polypharmacy program.
Possess the Ability To:
- Manage multiple, concurrent projects for completion in a thorough and timely fashion.
- Communicate well verbally and in writing.
- Analyze data and formulate sound conclusions and recommendations.
- Educate and persuade groups and individuals to alter behavior in accordance with program goals and objectives.
Experience & Education
- Doctor of Pharmacy degree preferred.
- A current, valid, unrestricted California State Registered Pharmacist License required.
- At least 3 years of experience in clinical pharmacy practice, or residency in Pharmacy Practice.
- At least 3 years of experience in managed care setting performing drug use evaluation and preparing drug monographs and other types of drug information for Pharmacy and Therapeutics Committees preferred.
- CMS, DMHC, and/or NCQA audit experience preferred.
- Current knowledge and expertise in clinical pharmacology and disease states required.
- Basic working knowledge of Medicaid and/or Medicare programs preferred.
- Bilingual is preferred.