Pharmacist

• 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

• Reports to the Assistant Director of Pharmacy and ultimately the Director of Pharmacy.
• Provides comprehensive professional pharmacy services for patients of all age groups.
• Complies with all Southern New Hampshire Medical Center Policies and Procedures.
• Supervises Pharmacy Technicians and Pharmacy Students per NH Board of Pharmacy Rules and Regulations.
• Interpret and safely implement all Medication Orders.
• Manage Emergent and Urgent situations.
• Prioritize tasks and work collaboratively with pharmacists and technicians to accomplish safe and efficient pharmaceutical care.
• Maintain training including continuing education per New Hampshire Board of Pharmacy rules and Medical Center required competencies.
• Demonstrate financial responsibility regarding provider non-formulary choices.

Clinical Pharmacist – Inpatient Pharmacy

• 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

Clinical Pharmacist – Medicare STARS

• Responsible for support and input to clinical programs such as: Health Management, Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high quality, cost effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place
• Participate in the Coverage Determination (Certification, Prior Authorization, Medical Exception, Exception to Coverage, etc.) process by reviewing all requests which are not clearly approvable based on specified criteria (algorithms), making all coverage denial determinations, and identifying themselves by first name, title, and responsibility at Navitus in relation to drug utilization management program administration
• Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers
• Provide input to clinical content of new programs and for maintenance of existing programs
• Complete all annual URAC training requirements
• Facilitation of communication and education to clients, members, and internal staff regarding clinical daily issues and objectives
• Provide support to operational departments on the implementation of various PBM programs and daily functioning in support of member/patient quality of care
• Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee
• May review health care survey data for Medicare Part D qualified participants and/or perform phone consultations with Med-D enrollees; aid in documentation of calls; designate enrollees for repeat interaction
• Other duties as assigned

Pharmacist I – Clinical Prior Authorization

• Review and render decisions on authorizations and appeals for specialty, non-specialty, and physician administered drugs
• Conduct peer-to-peer calls with prescribers to discuss the clinical rationale of adverse determinations
• Participate in clinical quality audits and inter-rater reliability testing
• Provide internal team support for escalations and questions
• Apply clinical expertise to ensure appropriate and safe use of pharmaceuticals by members and providers.
• Compliance with all applicable laws and regulations
• Other duties as assigned

Prior Authorization Pharmacist

• Use Oscar and vendor tools to determine eligibility, screen for required documents, create, process, and properly track pharmacy prior authorization requests
• Prepare, organize, and distribute pharmacy prior authorization requests for review by pharmacist/physician and respond to pharmacist/physician requests for additional information
• Collect relevant medical information (via telephone, fax, and portal) and apply the appropriate PA criteria, clearly documenting all communication and decision making
• Meet required decision-making timeframes, including promptly triggering escalation for cases requiring pharmacist review
• Communicate oral and written prior authorization outcome notifications that comply with standards and requirements for content and accuracy
• Compliance with all applicable laws and regulations
• Other duties as assigned

Prior Authorization Pharmacy Technician

• Operate within pharmacist-led clinical programs focused on chronic disease, quality improvement, and medication optimization.
• Activate on provided lists of eligible patients by outreaching, enrolling, and engaging patients. Maintain engagement through education, outreach, and follow-up.
• Conduct Medication Reconciliation, Medication Therapy Management (MTM), and Comprehensive Medication Reviews (CMR).
• Provide telephonic patient education on medication use, adherence, self-management, and escalation of care.
• Provide specific actionable medication recommendations and collaborate with providers, using technology and direct communication, to support practice adoption and medication management.
• Support other clinical programs to provide periodic consultation on pharmacy related issues affecting patients
• Drive medication adherence to address quality gaps
• Collaborating with the IDT—which includes primary care physicians, health coaches, and nursing staff—to develop patient-specific clinical action plans, reconcile medications, and make necessary adjustments to medications.
• Accelerate adoption of clinical insights by providers by driving uptake of actionable drug-related recommendations.
• Provide clinical feedback to enhance decision support logic, usability, and impact.
• Collaborate with Regional Medical Officers, Market Medical Directors, Practice Transformation Managers, care teams, and practices.
• Support consistent clinical standards, workflows, and messaging across markets.
• Support ideation and development of initiatives related to specialty medications, high-cost drugs, and pharmacy optimization programs.
• Partner with pharmacy and medical leadership on drug strategy aligned with value-based care goals.
• Document all clinical activity accurately and in accordance with state and federal regulations and HIPAA requirements, using provided platforms and technologies
• Serve as a pharmacy information resource for providers and internal clinical teams.
• Remain current on clinical guidelines, quality measures, and pharmacy best practices.

Clinical Pharmacist

• Troubleshooting electronic, faxed, and verbal prescriptions via routing to appropriate channels into pharmacy systems
• Review and update patient insurance using payer portals and phone resources
• Determining appropriate situations for a prior authorization (PAs) need via payer-specific tools; troubleshoot denials and escalations
• Utilize reroute best practices for orders falling outside normal workflow, including orders with state changes, insurance exceptions, pharmacy rejections, or failed transfers
• Navigate operational platforms (e.g., BestRx, Ops Dash, Partner Dash, RelayHealth, etc.) and vendor systems effectively
• Follow reroute protocols for specific tags including: non-contracted pharmacies, state shipping changes, PP send-backs, transfer not received, and more
• Proactively document process notes with clear routing details, claim updates, and actions taken
• Communicate with partner pharmacies, provider offices, and insurance carriers to resolve issues or clarify documentation
• Collaborate with At-Risk, Partner Management, and PPM teams to escalate or flag orders based on system outages, stock issues, or policy refusals
• Maintain productivity in the Reroute queue even during extended call hold times (e.g., multitask during insurance calls)
• Ensure all patient, prescriber, and partner communications are clear, professional, and aligned with Phil’s standards of care

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