Job Description
Title: Clinical Pharmacist
Duration: 3 months
Shift: 9am to 6pm EST
Responsibilities
- Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician’s recommended denial, suggested formulary alternatives, comments and attachments for appropriateness.
- Verifies member’s ID number and date of birth.
- Verifies member’s eligibility in the appropriate health plan eligibility system.
- Records carrier and group number if applicable.
- Checks for previous prior authorization decisions.
- Verifies coverage in member’s prescription benefit when necessary.
- Verifies coverage in member’s health plan benefit when necessary.
- Evaluates prescription claim history.
- Reviews chart notes and/or lab values.
- Identifies provider specialty when appropriate.
- Applies Medical Policy Criteria to prior authorization requests.
- Evaluates whether request meets criteria for approval.
- Reviews the request using professional clinical judgment on a case by case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.
- Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool
- Communicates with physicians regarding prior authorization:
- For a non-formulary drug
- Plan benefits, exclusions
- Quantity limits
- Age restrictions
- Formulary alternatives
- Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department)
- Compiles data for reporting purposes:
- Drug utilization of non-formulary drugs
- Overturned IPS recommended denials
- Audit pharmacy claims greater than $200.00
- Suggest addition or deletion of drugs to/from the formulary
- Updating qty/days or age limit ends
- Support National P&T Committee
- Other tasks which may arise during the performance of any of the above mentioned duties.
Education/Certification Required: Pharm D.
Licensure Required: FL Pharmacist license
Must haves: At least one year of professional RPh experience
Nice to haves: Some experience working in managed care, understanding of Medicare/Medicaid law
Performance indicators:
- Sign 85 – 100 cases daily
- Self-Motivated/Good Time Management Skills
- Working Knowledge of Office Suite
- Goal Oriented