Clinical Pharmacist I (Utilization Management)

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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary

Reporting to the Manager of Clinical Pharmacy Operations, the Clinical Pharmacist I (UM) is primarily responsible for the pharmacy utilization management (UM) activities, including review of all pharmacy prior authorization requests, oversight of the UM activities of the Pharmacy Services support staff, maintenance of pharmacy UM programs, provide clinical peer-to-peer consultation as needed, provide pharmacy-related customer service to internal and external parties, and serve as a subject matter expert for claims issue resolution. In addition, the Clinical Pharmacist I (UM) may provide implementation support for formulary management decisions and clinical policies and provide peer trainings as needed. The Clinical Pharmacist I (UM) may also participate in care management activities as needed.

Key Functions/Responsibilities

• Participation in prior authorization, formulary exception, step therapy and quality limit program implementation and management for all lines of business
• Conduct pharmacy prior authorization decisions consistent with covered benefits, clinical policies, medical necessity for both pharmacy and medical distribution channels
• Ensure that pharmacy prior authorization requests and decisions are properly evaluated, documented and are compliant with all regulatory and accreditation requirements
• Provide oversight of Pharmacy Operations analysts in executing day-to-day approvals and denials in order to maintain compliance with all regulatory requirements.
• Support product portfolio, which includes rotational weekend and holiday support for timely determinations.
• Provide clinical peer-to-peer consultations
• Responsible for analysis and issue resolution as it pertains to the administration of the formulary and benefits
• Provide pharmacy-related customer service to both internal and external parties.
• Responsible for insuring pharmacy programs meet applicable industry, regulatory, accreditation and contractual standards or laws
• Collaborate with clinical and non-clinical teams for staff trainings, facilitation of meetings and other ad hoc presentations.
• Participate in the development and design of drug utilization programs and new clinical program opportunities
• Facilitate special projects as assigned
• Develop drug information, training, and support to all internal and external customers
• Develop strategies for effective communication of program initiatives in partnership with Clinical Pharmacy for internal and external customers
• Identify opportunities for workflow efficiencies and new clinical quality and cost saving programs
  
  

Supervision Exercised

• May provide guidance and direction to pharmacy operations specialists
  
  

Supervision Received

• General supervision received weekly
  
  

Qualifications

Education Required:

• Bachelor of Pharmacy
  
  

Education Preferred

• Doctor of Pharmacy preferred
• Graduate study in a business, public health, or health policy field
  
  

Experience Required

• At least 5 years clinical experience or completion of an accredited residency program required
  
  

Experience Preferred/Desirable

• Experience in direct supervision of technical support staff for clinical and/or service and operational programs is desirable.
• Experience in a managed care setting, either from the provider, the payer, or the PBM side of the industry, is preferred.
  
  

Required Licensure, Certification Or Conditions Of Employment

• Successful completion of pre-employment background check
• Unrestricted current and valid license to practice pharmacy in the state of Massachusetts and/or in any other relevant/applicable state
• MTM Certification is desirable
  
  

Competencies, Skills, And Attributes

• Excellent written and oral communication skills
• Excellent interpersonal skills
• Strong organizational and time management skills, including ability to work independently and prioritize multiple projects and assignments
• Demonstrated strength in analysis, identification of problems and issue resolution
• Excellent skills in teamwork and team approaches to goal setting and attainment
• Must be results oriented
• Proficiency in standard computational office-suite applications, including word-processing and relational database manipulation is required
  
  

Working Conditions And Physical Effort

Regular and reliable attendance is an essential function of the position.

Occasional travel (<5%) may be required

Ability to work in a fast paced environment

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

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