Clinical Pharmacist I (Utilization Management)

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 Pharmacy Services, the Clinical Pharmacist I 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, and maintenance of existing pharmacy UM programs. In addition, the Clinical Pharmacist I supports the department by coordinating the activities of the health plan’s pharmacy benefits manager (PBM) and formulary advisory committees (Pharmacy and Therapeutics Committee). The Clinical Pharmacist I may also participate in care management activities such as MTM, case reviews and such, as needed.



Our Investment in You:

· Full-time remote work

· Competitive salaries

· Excellent benefits



Key Functions/Responsibilities:

· Ensure that pharmacy prior authorization decisions are consistent with covered benefits, quality of care and medically necessity.

· Ensure that pharmacy prior authorization requests and decisions are properly evaluated, documented and meet all applicable utilization management turn-around times.

· Responsible for insuring pharmacy programs meet applicable industry, regulatory, accreditation and contractual standards or laws.

· Researches new prescription drugs or new applications of existing drugs and develops prescription drug use recommendations.

· Works with the (PBM) to identify areas of potential cost-saving and quality improvement.

· Gathers clinical and financial information for presentation to the health plan’s Pharmacy and Therapeutics Committee.

· Participates on clinical committees as necessary.

· Conducts medication reconciliation outreach phone calls to members enrolled in care management programs.



Qualifications:

Education:

· Licensed in the state of Massachusetts as a Pharmacist.

· Bachelor of Pharmacy.

· Pharmacy & Therapeutics Committee experience preferred.

· Doctor of Pharmacy preferred.



Experience:

· 1-2 year’s clinical experience.

· Pharmacy & Therapeutics Committee experience preferred.

· Managed Care experience preferred.



Required Licensure, Certification or Conditions of Employment:

· Valid unrestricted Massachusetts state pharmacy licensure.



Competencies, Skills, and Attributes:

· Extensive knowledge of drug products, medical therapeutics, pharmacokinetics, and disease states.

· Must be proficient in Microsoft Office.

· Strong written and verbal skills.

· Demonstrated ability to review & analyze data.



Working Conditions and Physical Effort:

· Occasional travel (Apply To This Job