AddressDescription
MMM Holdings, LLC is a company that provides Medicare Advantage and Medicaid plans in Puerto Rico. Currently, MMM Holdings, LLC operates in Puerto Rico under Elevance Health, Inc. a leading health company dedicated to improving the quality of life of communities in the United States. Through its affiliated companies, they serve more than 118 million people.
Pharmacist Clinical
Location: This position will work a hybrid model (days in office will vary depending on the unit's need). When reporting to the office, the location will be on 411 c/ segarra Sector Bechara Marginal Ave Kennedy San Juan, PR 00936.
Job Description
Responsible for managing the selection and utilization of pharmaceuticals and supports core clinical programs such as DUR, DIS and formulary management.
Primary duties may include, but are not limited to:
Researches and synthesizes detailed clinical data related to pharmaceuticals.
Prepares and presents therapeutic class reviews and drug monograph information to the Pharmacy and Therapeutics Committee.
May review and approve or deny coverage for pharmaceuticals (as permitted by state/federal law or state/federal program contracts) based on medical necessity criteria, and coordinates with Elevance Health or health plan medical directors as needed.
Serves as a clinical resource to other pharmacists on areas such as prospective, inpatient and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions.
Prepares information for network physicians.
How you will make an impact
In conjunction with the Director of Formulary and Utilization Management is responsible for managing monthly CMS formulary maintenance submissions and the annual submission process.
Through internal quality review assure that marketing materials for formulary changes and clinical criteria notification via the public websites in all its forms is performed accurately and on time, as required by CMS.
Support the development of formulary utilization management programs as needed for all formulary submissions.
Support in the review and documentation of the annual CMS Outlier review process.
Support in the review and documentation of the annual CMS UM Criteria review process.
Maintain custom formulary lists and review Medispan reports as provided.
Support OTC coding activities. Support during internal and external audits related to the formulary.
Execute utilization reports for clinical, financial, auditing and other purposes.
Support of Clinical Practice Consultants utilization management strategies
Participates in the development of strategies affecting drug utilization related to or involving quality programs, surveillance FWA programs, formulary, and other pharmacy clinical programs.
Assists in the implementation of pharmacy related educational programs.
Support AEP formulary consults.
As part of the clinical team support the preparation of Pharmacy and Therapeutic Committee meeting, including documentation, new drugs presentation, utilization analysis and therapeutic class review.
Conducts other responsibilities as set by Director of Formulary and Utilization Management.
Requirements:
Requires BA/BS in Pharmacy. Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background. Requires a registered pharmacist. Must possess an active unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh). PharmD preferred.
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US, unless they are command-sanctioned activities.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. For associates working within Puerto Rico who are member or patient facing either in a clinical setting, a current PR health certificate and a current PR Law 300 certificate are required for this position.
Preferred qualifications:
Doctor in Pharmacy degree in Pharmacy from an accredited college/university.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.comfor assistance.
