Responsibilities
- Conduct patient-specific medication reviews and formulate recommendations based on established medical treatment protocols and clinical practice guidelines, adhering to regulatory timelines and standards.
- Manage medical drug utilization by evaluating and adjudicating prior authorization requests for medical drugs.
- Assess drug claims for clinical appropriateness.
- Perform Comprehensive Medication Reviews as part of Medication Therapy Management, complying with CMS standards and timelines.
- Evaluate and develop medication adherence recommendations for members and prescribers.
- Coordinate with members, prescribers, and pharmacies to ensure patients obtain medications and understand usage instructions.
- Support pharmacy clinical quality priorities, including HEDIS, MCAS, and STARS measures, by evaluating and developing patient-specific recommendations.
- Resolve medication and pharmacy issues for members referred from the Member Services Call Center or other internal departments.
- Assist with formulary implementation, management, and maintenance.
- Communicate clinical recommendations verbally and in writing to members, prescribers, and pharmacies regarding medication use, adherence, therapy changes, and risks.
- Initiate outbound calls to members and prescribers to explain clinical recommendations developed during medication reviews.
- Serve as a subject matter expert for internal and external regulatory and operational audits, projects, quality improvement process enhancements, LEAN projects, and other initiatives.
- Perform any other duties assigned by Pharmacy Leadership to ensure successful Health Plan operations.
Requirements
- Two or more years of experience in a managed care pharmacy setting, or successful completion of a one-year Pharmacy Managed Care residency.
- Doctor of Pharmacy degree from an accredited institution.
- Active, unrestricted, and unencumbered Registered Pharmacist license issued by the California State Board of Pharmacy.
- Strong clinical baseline knowledge of current medical treatment protocols and clinical practice guidelines.
- Working knowledge of regulatory standards and timelines for Medi-Cal, Medicare, and Covered California lines of business.
- Excellent written and verbal communication skills.
- Strong drug information research skills.
- Excellent communication and interpersonal skills.
- Detail oriented.
- Ability to communicate and work effectively with a variety of stakeholders and maintain positive working relationships with internal and external contacts at all levels.
Nice to Have
- One year of medical drug prior authorization and/or Medication Therapy Management experience.
- Bilingual.
- Proficiency with health plan electronic medical records systems such as MHK or Meditrac.
Benefits
- Competitive salary
- CalPERS retirement
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- CalPERS retirement 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance
Compensation
Competitive salary
Work Arrangement
Hybrid — Telecommute
Other
- Schedule will adjust based on business need which may include evenings, holidays, and weekends.
- Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval.
- All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership.
