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Pharmacist II

Company: Amerihealth
Location: Southfield
Posted on: July 11, 2021

Job Description:

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

  • Review appropriate clinical material (primary literature, clinical guidelines, etc.) to prepare medication reviews
  • Prepare all clinical material
  • Review physician inquiries for pharmacy, physician-administered, or home infusion pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria
  • Handle calls and correspondence from providers; responds to inquiries, complaints and reconsiderations. Document calls in inquiry tracking system.  Using established protocols, ensure resolutions provided are presented in a clear and accurate manner. Receive escalated calls that cannot be clinically resolved by 1st and 2nd level intervention. Research, resolve and respond to Provider clinical inquiries.
  • Support Fraud and Abuse program system oversight. Communicate any suspected fraud discovered by the Contact Center staff. Recommend course of action for Providers where patterns appear outside of guidelines and generally accepted pharmacy standards.
  • Review patient profiles for high utilizing members. Determine instances of therapeutic duplications, adverse drug combinations, and general areas where therapy falls grossly outside of AMFC guidelines. Work with supervisor and various internal and external providers to establish positive outcomes for the member as well as AMFC.
  • Review and complete assigned Prior Authorization requests on a daily basis; assist Prior Authorization Department when additional resources are needed
  • Assist supervisor in coordinating department staff projects including coordinating patient care with internal and external practitioners, pharmacist disease specialties, pharmacy journal club, and new drug information
  • Assist in monitoring and organizing daily workflow and productivity as well as providing Quality Assurance reviews of denied prior authorization requests
  • Represent AmeriHealth Caritas in contacts with Providers, members, hospital personnel, etc.  Demonstrate an understanding of AmeriHealth Caritas' protocols for dealing with external organizations, groups, vendors, and individuals.  Monitor new drugs released to the market and performs clinical reviews.  
  • Research data on new/existing drugs and review test trial results. Conduct Drug Utilization Reviews (DUR), review DUR patterns and provide findings and recommendations to Formulary Manager for action. Monitor the operations of the assigned Clinical Program. Coordinate data compilations, system updates, information and quarterly reporting.
  • Keep abreast of industry trends and regulatory changes in the pharmacy industry and evaluates their effect on pharmacy contracts and services.  Make recommendations on program improvements, based on findings and utilization. 

OPEN TO CANDIDATES NATIONWIDE

Education/Experience:

  • Bachelor’s Degree required
  • Current pharmacy license in applicable state preferred
  • Pharm D. preferred
  • Minimum three (3) years of current/recent managed care experience required 
  • MTM/DTM Certificate training preferred

Keywords: Amerihealth, Southfield , Pharmacist II, Other , Southfield, Michigan

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