Pharmacist

• Create and Maintain Clinical Criteria for applicable Utilization Management (UM) programs: Develop and maintain clinical criteria (access to Prime standard and BCBSNE specific versions); Develop and maintain criteria process flows; Develop and maintain physician fax forms and other modes of communication; Utilize predictive modeling tool to intervene with high-risk members for identified disease states; Provide clinical updates as necessary to internal staff and physician reviewers; Performs highly complex research, analysis and develops recommendations for UM programs & plan design changes.
• Responsible for Operational workflows and Completion of UM reviews: Clinical oversight of first level review process; Clinical review of utilization management reviews; Perform clinical support for Pharmacy Technician and other staff; Utilize reporting tools to create efficiencies by reviewing medical and pharmacy claims data; Support physician reviewers with information required to efficiently review non-approvable claims; Develop Decision Tree review process when applicable.
• Maintain URAC accreditation: Work with internal staff to ensure that URAC accreditation is maintained; The pharmacist will work within their scope of licensure and unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting drug utilization review. The clinical pharmacists may not conduct peer clinical review non-certifications for drug utilization management, if prohibited by state utilization management laws. The clinical pharmacists may not conduct peer clinical review non-certifications for drug utilization management if the requesting party specifically requests a clinical peer.
• Measure quality assurance reporting, turnaround time for urgent and non-urgent reviews and quantitative assessment of UM reviews by program.
• Support Medicare Advantage processes, outreach, presentations, and tasks that require clinical direction and support. This includes, but not limited to, clinical presentations to internal and external stakeholders, providers, provider offices, and other customers.

Clinical Pharmacist

• Ensure accurate entry of orders
• Maintain security of the pharmacy
• Adhere to required delivery schedules
• Verify orders entered by technician staff for accuracy
• Check for completeness and precision of all new and refill labels and orders
• Check for content and accuracy of all drug packaging and labeling
• Preparation and/or supervision of sterile IV drug products or solutions, if required
• Assist in maintaining a perpetual inventory for schedule II drugs
• Knowledge of DEA and state law with regards to controlled drug dispensing
• Provide evening, weekend, and holiday coverage during scheduled rotation based on the needs of the business
• Follow all applicable state and government regulations including HIPAA
• Other duties as assigned

Dispensing Pharmacist – Long Term Care

• Submit and manage prior authorization requests for medications only, as required by insurance carriers.
• Review physician medication orders, supporting clinical notes, and documentation to ensure prior authorization requests are complete and accurate.
• Track medication prior authorizations from submission through approval, denial, or request for additional information.
• Follow up with payers to ensure timely determinations and minimize delays in medication access.
• Coordinate prescription refills in collaboration with providers and pharmacies.
• Serve as the primary point of contact for pharmacies regarding medication-related questions, clarifications, and insurance requirements.
• Support enrollment and coordination of patient assistance programs for medications when applicable.
• Communicate with patients regarding medication-specific authorization requirements, timelines, approvals, denials, and next steps.
• Identify medication prior authorization denials and coordinate appeals when appropriate.
• Manage assigned work queues, tasks, and follow-ups to meet defined turnaround times.
• Maintain compliance with payer requirements, HIPAA, and organizational policies.

PSC, Medication Prior Authorization, Pharmacy

• Acts as a liaison between Finance, Analytics, IT and Pharmacy
• Focus on understanding data content and the business logic behind all data transformation for reporting
• Develop expertise in the data and systems leveraged internally and externally for the Pharmacy Department
• Gather requirements, perform analysis, support the development and testing of processes
• Understand and document the applications, data and associated technologies for the Pharmacy Department

Senior Pharmacy Performance Specialist

• Provide consultations through the patient's preferred method of communication (text, app messaging, email, or phone)• Perform initial assessments by gathering/reviewing chart notes to determine appropriateness of prescribing patterns• Perform clinical check-ins to monitor adherence, efficacy, adverse reactions, and drug interactions• Identify patients in need of clinical interventions and work collaboratively with providers to provide therapeutic recommendations resulting in improved patient outcomes• Ensure transition of care by transferring out prescriptions to appropriate pharmacies in situations where Alto is unable to fulfill a patient’s prescription• Being responsible for communicating prescription statuses to patients and providers• Work closely with Specialty Operations to provide quality care through the following:• Maintain an in-depth understanding of pharmacy billing including but not limited to Medicaid, Medicare, ADAP, commercial insurance, and foundation assistance programs to help troubleshoot patient cost barriers• Proactively identify and communicate areas of concern regarding scheduling/delivery procedures• Develop and provide drug information material designed to enhance Specialty Operations’ performance• Stay abreast of relevant and evolving regulatory and industry standards, ensure that appropriate action is initiated, and communicate these trends to applicable personnel• Work interactively with a local and/or dispersed team to achieve company business and compliance goals/objectives

Patient Care Pharmacist – Short Term Assignment

• Demonstrates comprehensive knowledge of current pharmacotherapeutic principles, medical terminology, pathologies, disease state and population management, age appropriate therapy, and other information as related to medical and/or pharmaceutical care management.
• Work with Sentara Health Plan (SHP) members to close medication-related gaps in care
• Work on the referrals from the team
• Counseling members on their medication therapy

Pharmacist jobs in Kansas

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Clinical Pharmacist

Dispensing Pharmacist – Long Term Care

PSC, Medication Prior Authorization, Pharmacy

Senior Pharmacy Performance Specialist

Patient Care Pharmacist – Short Term Assignment

Clinical Pharmacist – Medicare STARS