CareFirst Medicare Clinical Pharmacist in Baltimore, Maryland
Resp & Qualifications
The Medicare Clinical Pharmacist will perform comprehensive clinical services involving oversight of clinical programs, vendors and internal processes to comply with program guidelines and requirements. Responsibilities will include but are not limited to; maintaining and updating drug formularies, utilization management reporting and review, clinical drug evaluations, development of drug management tools, and oversight of delegated programs. The Medicare Clinical Pharmacist may also perform patient education, medication counseling, drug therapy monitoring, and chronic disease state management for patients in clinical programs such as Medication Reconciliation Post-Discharge and Medication Therapy Management.
Tracks productivity, quality, impact, and overall performance of clinical pharmacy programs, formularies, and/or utilization management. Identifies areas where program modifications could result in improvements to patient outcomes and reduce costs. Works collaboratively with vendors, PBMs, and internal parties for oversight of programs and performance management. Participates in the development and execution of initiatives to improve quality measures.
Performs telephonic therapeutic consultations to patients and/or prescribers. Completes a pharmacotherapy assessment of patient's claims, past medical history and disease states. Provides clinical recommendations pertaining to, but not limited to, adverse events, therapeutic duplication, adherence to therapy, polypharmacy, high risk medications, therapeutic substitution, and untreated disease or conditions. Utilizes formulary information and member specific benefits to guide appropriate medication recommendations. Completes medication reconciliation post-discharge cases, oversees and participates in completing comprehensive medication reviews as part of the Medication Therapy Management program. Details providers, evaluates fraud, waste and abuse via claims review, and monitors clinical trends.
Develops and provides formal written and verbal presentations or other communication materials related to clinical pharmacy programs, pharmacy utilization, pharmacy strategy, and pharmacy topics to a broad audience including both internal and external stakeholders including, but not limited to members, CMS, sales, and committees.
Ensures pharmacy programs are compliant with Centers for Medicare and Medicaid Services (CMS) regulations. Responds to requests from CMS or other governing bodies as directed by leadership. Helps prepare and respond to annual submissions, audit requests, and routine compliance memos.
Works with internal and external partners to support eligibility and claims issues that require clinical expertise. Participates in benefit oversight, coding, and testing of Medicare pharmacy benefits.
Education Level: Medical Degree in Pharmacy (Doctorate of Pharmacy).
Experience: 5 years experience in clinical pharmacy, preferably in a managed care environment.
PHARMD - Licensed Pharmacist Active Maryland Registered Pharmacist.
Experience in Medicare and/or Medicaid
Experience working in healthcare industry with a thorough understanding of prescription benefit management programs and practices.
Knowledge, Skills and Abilities (KSAs)
Ability to work independently, as well as a member of a team .
Strong critical reasoning skills in clinical decision-making, planning and organizing.
Current knowledge of clinical practices and related information systems and computer applications, required.
A strong balance between clinical expertise and business acumen.
Strong interpersonal, written and verbal communication skills, including presentation skills.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Department: Medicare Advantage-Maryland
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before:2.12.2022
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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