Coverage Determination Pharmacist

The Coverage Determinations Pharmacist reports to the Clinical Manager. The Coverage Determinations Pharmacist will review, evaluate, communicate, document, track, and make determinations within the protocol for pharmacy benefit Coverage Determination requests such as requests for formulary exceptions, prior authorization (PA), step therapy (ST), and quantity limit (QL) exceptions, and override processes for formulary exceptions (e.g. product service not covered (PSNC)) and delegated utilization management (UM) products and services based upon regulation and defined procedures. The Coverage Determination Pharmacist will review and evaluate Coverage Determination requests for the clinical opportunity to address the appropriateness of therapy, clinical interventions, generic substitution, or therapeutic interchange opportunities with potential cost savings outcomes, and/or interventions. This individual will assist with efforts to initiate, support, and continue cost-effective, rational drug and disease therapy, utilizing distinct but inter-related clinical management and cross-departmental functions that focus on improving the health of members while reducing overall health care costs.

ESSENTIALS ROLES AND RESPONSIBILITIES

1. Evaluate formulary utilization management program (Prior Authorization (PA), Step Therapy (ST), Quantity Limit (QL), Product Service Not Covered (PSNC), and drug utilization review (DUR), including concurrent, prospective, and retrospective DUR, such as Drug-Drug Interaction, Dose Check, Drug-Pregnancy Precaution, Drug-Age Precaution, Drug-Gender Precaution, Duplicate Therapy, and Drug-Disease Interaction) alerts.
2. Perform Coverage Determinations on drug coverage by reviewing and analyzing requests for prescription drugs; relay denial or approval to the requester following verification of member benefits, medical diagnosis, and review of information regarding the requested prescription drug.
3. Manage and be the subject matter expert of the Coverage Determination and PA processes and protocols by updating and creating program criteria, policies and procedures, and functional operation to ensure program success and program goal achievement of enhanced therapeutic outcomes for targeted plan beneficiaries through improved medication use.
4. Responsible for interfacing with physicians, pharmacists, and pharmacy providers concerning members’ benefits and therapeutic interventions and reviewing/evaluating the Coverage Determination requests and utilization data for program management and development.
5. Responsible for the protocol development, maintenance, and administration of prior authorization programs and medical necessity reviews.
6. Responsible for processing prior authorization requests following standards for accuracy, timeliness, productivity, and client performance commitments.
7. Responsible for the Coverage Determination process, reviewing all requests which are not approvable based on specified criteria (algorithms or protocols), making all coverage denial determinations concerning drug utilization management program administration.
8. Responsible for the coordination, operation, and development of prior authorizations.
9. Design, develop and/or deliver training to address identified needs or gaps in performance or knowledge with clinical department staff relating to prior authorization clinical content.
10. Design and implement prior authorization, appeals, and other utilization management programs for new and existing clients, including design and development of standard and customized prior authorization and appeals notification letters.
11. Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers.
12. Provide input to clinical content of new programs and for maintenance of existing programs.
13. Responsible for staying current with clinical literature and guidelines and relaying those to the program development core teams.
14. Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers.
15. Provide feedback to Clinical Specialists regarding the processing of PA cases referred for clinical review. Provide in-service education to Clinical Specialists regarding topics such as PA guidelines or diagnoses commonly seen as part of the PA review process.
16. Provide input to clinical content of new programs and for maintenance of existing programs.
17. Responsible to assist in prior authorization template updates.
18. Maintain prior authorization benefit designs with a high degree of accuracy as validated through audits and testing.
19. Participate in the planning, documentation, and implementation of policies and procedures to ensure application setup and maintenance that is consistent with company goals, industry best practices, and regulatory requirements.
20. Maintains confidentiality of all protected health information (PHI), personally identifiable information (PII), and other sensitive materials.
21. Exhibit compliant and ethical behavior in the performance of job responsibilities, including complying with all applicable federal and state laws and regulations, PharmPix’s Code of Ethics, Standards of Conduct, and any applicable policies and procedures.

1. Maintain professional affiliations, certifications and enhances professional development to keep current in the latest healthcare trends and developments.
2. Participate in any PharmPix Quality Management Program initiatives that may impact Clinical Account Management.
3. Participate in the Pharmacy Monthly Meetings by attending monthly and presenting educational topics quarterly.

1. Provide clinical feedback in support of utilization management and formulary placement related to the Pharmacy & Therapeutics (P&T) Committee.
2. Attend all P&T meetings.

TRAINING & EDUCATION

• B.S. in Pharmacy or PharmD.
• Completion of a Residency in Managed Care desired.
• Academy of Managed Care Pharmacy (AMCP) Managed Care Certification or certification within the first six months of employment.

LICENSURE/CERTIFICATION

• Current, valid, and unrestricted state or local pharmacist license.
• Active membership in a state or local pharmacy association.

PROFESSIONAL EXPERIENCE

• Two (2) to five (5) plus years related experience and/or training in Coverage Determinations or similarly related duties (preferred).
• Or equivalent combination of education and experience.

PROFESSIONAL COMPETENCIES

Knowledge:

• A thorough understanding of the managed care industries from the perspective of Pharmacy Benefit Managers and providers of care.
• Comprehension of Medicare Part D rules and regulations.
• Knowledge of the rules and regulations promulgated by the US Congress related to pharmacy benefits, especially the Medicare Modernization Act of 2003.
• Knowledge of federal health care delivery and pharmacy regulations/regulatory agencies.
• Knowledge of financial aspects of managed care contracts, financial data, and compliance.
• Knowledge of Microsoft Access, Word, Excel, PowerPoint, and Outlook, as well as Internet Explorer.
• Knowledge of the Commonwealth of Puerto Rico health care delivery and pharmacy regulations/regulatory agencies (preferred).

Skills:

• Demonstrated effective organizational and communication skills.
• Skill in analyzing situations accurately and taking effective action.
• Skill in exercising a high degree of initiative, judgment, discretion, and decision-making to achieve organizational objectives.
• Skill in exercising judgment in applying, interpreting, and coordinating departmental policies and procedures.
• Skill in negotiations and diplomacy.

Abilities:

• Ability to develop and maintain productive relationships with other internal departments, PharmPix clients, and other health care professionals.
• Ability to engender a team spirit at all levels of the organization.

• Ability to learn and convey medical and formulary technical information at the level of the client, member, or healthcare professional.
• Ability to obtain a National Provider Identification Number (NPI) for designated taxonomy.
• Ability to work in a fast-paced environment and multitask.

PHYSICAL AND MENTAL DEMANDS

• The physical demands described here represent those that must be met by an employee to perform the essential functions of this job successfully. While performing this job's duties, the employee is regularly required to talk or hear, sit, stand, and walk.
• The position requires that up to 25 pounds of weight be lifted.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

PharmPix is an Equal Employment Opportunity Employer Minorities / Females / Disable / Veterans