Facilitates efforts in the development of medical pharmacy solutions programs including PA criteria development and coordination of Pharmacy and Therapeutic Committee (P&T) and DUR Board meetings.
Supports Prospective and Retrospective drug utilization review (DUR) efforts by reviewing physician prescribing patterns, consulting with physicians regarding these patterns using evidence-based best practices, working closely with internal staff in the refinement of the medical pharmacy management solutions programs, providing consultation on pharmacy issues to clinical operations representatives and facilitating the successful implementation of these programs for customer organizations. Primary activities center on discussions with practicing physicians (and other prescribers) to consult on prescribing of specialty medications. Coordinates with operations, clinical, medical, reporting, and other internal departments as needed.• Prior Authorization Criteria Development: Evaluate drug and drug class reviews based on sound evidence-based research and processes widely accepted by the medical profession.
Ensuring evidence summaries inform the recommendations for management of the preferred drug list (PDL) and clinical prior authorization (PA) criteria. Using appropriate methods that support the principles of high-quality evidence-based medicine. Develop clinical PA criteria recommendations and documents to present to P&T and/or DUR Board. • Providing a thorough review of the clinical and pricing data to assist the P&T Committee or DUR Board in reviewing the Gainwell clinical criteria and PDL recommendations in order to make coverage and PDL placement decisions. • Retro DUR Initiatives: Regularly reviews and monitors prescription claims data and prescribing practices identified as outliers by internal and/or external analysis of pharmacy claims data to develop relevant Retrospective DUR initiatives. Present initiatives to the P&T or DUR Board including methods, interventions, communication, and outcomes. • Telephonic Consultations/Interventions: Contacts physicians and prescribers identified as needing consultation to provide coaching on prescribing practices that have been identified as outliers. Reviews prior authorizations and determine opportunities for interventions. • Intervention Tracking and Documentation: Tracks contact attempts and contacts per operations procedures. Documents content of and results of consultations as defined in operations procedures; maintains records as required. • Intervention Refinements: Collaborates on the refinement of consultation scripting; solicits and utilizes input from those contacted toward scripting improvements. • Operations: Contributes to the success of the operations of the pharmacy program by assisting with the implementation and management of both written and verbal communications to physicians and prescribers and maintenance of the edits and data elements that support the edits. Is available for consultation on pharmacy-related questions and issues for others within the organization (e.g. health coaches, care managers, etc.). Updates and maintains program engine, coding, consultation sheets and outreach program as needed. • Quality Improvement: Contributes to program improvements by using continuous quality improvement processes, by being proactive in identifying improvement opportunities and by contributing on-going consultation and collaboration with product leaders. • Medical/Clinical: Upholds clinical integrity of pharmaceutical solutions by staying up to date on medication information, contributing to the identification of pharmacy program best practices, collaborating with Medical Directors, Medical Dept, and Clinical Dept and provides pharmacy expertise within the organization. • Other duties as assigned. Contributes creative solutions to improve operational efficiency and effectiveness of pharmacy team.• Management experience in the coordination of and collaboration of work teams preferred.
• 5 years' experience in clinical pharmacy • Ability to perform clinical reviews using relevant compendia and clinical trial data. • Managed care pharmaceutical service experience plus experience with coaching physicians and prescribers on medication issues, especially on specialty medications. • Knowledge of current research related to specialty medications. • Strong research and implementation skills in practical settings. • Analytical skills which can translate into practical and pragmatic recommendations. • Strong team orientation with respect for all members. • Strong verbal and written communications skills. • People skills are essential that allow for the successful consultation with physicians, prescribers and pharmacists and for successful collaboration with company employees and external vendors who do not directly report to this job. • Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems.Reside in or around CT with an active Pharmacist license.
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