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Responsibilities:
- Support clinical pharmacy operations across Medicare populations, providing expertise in medication management, prior authorization, utilization management, and member care.
- Utilize proprietary dashboard to track personal key performance metrics.
- Complete pharmacy referrals using PBM claims databases to obtain comprehensive medication histories and evaluate appropriate dosing, drug interactions, adherence, and opportunities for clinical intervention.
- Specialize in referrals involving STARS medications, identifying opportunities to improve safety, adherence, outcomes, and affordability.
- Conduct outreach to members regarding medication-related questions, affordability concerns, pharmacy issues, and potential non-adherence.
- Collaborate with providers to address drug interactions, medication regimen optimization, and gaps in care.Â
- Serve as a primary point of contact for pharmacy-related questions, claim rejection issues, affordability concerns, and medication access barriers.
- Research prior authorization denials and provide case managers and members with guidance regarding appeal opportunities, documentation requirements, and next steps. Â
- Coordinate with providers, PBMs, pharmacies, and members to facilitate prior authorization completion, claim overrides, medication access, and resolution of pharmacy-related issues.
- Maintain established productivity, quality, compliance, and service-level standards across pharmacy operations.
- Manage complex member escalations and grievances, ensuring timely resolution and appropriate clinical follow-up.
- Counsel members on medications, including appropriate use, adherence, safety considerations, and potential medication-related concerns.
- Perform Comprehensive Medication Reviews (CMRs) and identify opportunities for medication optimization, adherence improvement, and cost savings.
Work Experience:
- Managed Care, Insurance, PBM experience required
- Pharmacist experience: 2 years
Education and Skills:
- Bachelor’s degree in Pharmacy
- Proficient in Microsoft Office Suite
- Excellent communication skillsÂ
- In-depth knowledge of pharmacy benefits managementÂ
- Attention to work-related detailsÂ
- Excellent problem solver and team leader
License/Certification: Registered Pharmacist
Equal Opportunity Employer:Â We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
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