Senior Clinical Pharmacist

Senior Clinical Pharmacist

Location: Birmingham, AL

Work Schedule: Hybrid schedule with regular work onsite at the VIVA HEALTH corporate office and some work-from-home opportunities.   

The Senior Clinical Pharmacist will provide leadership at the health plan regarding clinical pharmacy decisions and programs. This position will assist departmental leadership with Quality Assurance (QA) of coverage determinations reviewed by the Clinical Pharmacist, serve as a clinical reviewer for the Plan’s Medicare Part D Coverage Determinations, and serve as the subject matter expert for Opioid Part D reporting requirements.

This individual will monitor prescription drug utilization, coverage policies, and costs to identify and address issues related to quality and cost-effectiveness. This role will assist in training of new pharmacists and support the Pharmacy Department’s efforts towards attainment of a minimum 4 Star CMS Medicare Advantage Plan Star Rating.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Healthcare Reimbursement Account
• Paid Parental Leave
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits

Key Responsibilities

• Assist with QA of coverage determinations reviewed by the clinical pharmacists and report findings to management.
• Maintain and apply criteria for drug related coverage determinations, exception requests, complaints, and appeals and ensure criteria and decisions are properly communicated and applied. Research individual cases and render decisions in consultation with the Pharmacy Department Management or Medical Director if required.
• Assist in training of new coverage determination pharmacists.
• Create and maintain training guides and job aids for the pharmacists to use when reviewing coverage determinations.
• Support pharmacists and management with maintenance and development of policies and procedures as required by CMS regulations.
• Assist management with preparation for regulatory reviews and audits and participate as needed.
• Participate in on-call rotation for coverage determinations to satisfy CMS requirements and regulations, including periodic weekend and holiday work.
• Assist the Department in monitoring drug cost and utilization trends in aggregate and on a patient specific basis to identify quality issues as well as clinically appropriate cost-saving opportunities. Assist with development and implementation of procedures for addressing these opportunities such as physician and member communications (one-one or general), programs in conjunction with internal or external stakeholders, and benefit/formulary adjustment recommendations.
• Collaborate with the Pharmacy Benefit Manager(s) (PBM) and assist with clinical oversight of benefit administration. This includes formulary selection and maintenance, application of utilization management tools (prior authorization, step therapy, quantity limits, etc.), review of member disruption related to formulary changes and drug recalls, and drug review criteria.
• Attend and prepare clinical updates for the Plan’s oversight committees as needed including the Pharmacy & Therapeutics Committee and Utilization Management/Quality Improvement Committee.
• Develop and present training, reports and other communications for internal staff, providers, and other stakeholders related to clinical pharmacy issues, such as drug pipeline information.
• Participate in development and execution of strategies to support achievement of a 4 Star minimum CMS Medicare Advantage Plan Star Rating.
• Serve as the subject matter expert for Opioid Part D reporting requirements.
• Participate in Pharmacy Student mentoring, education, and development as needed.

REQUIRED:

• Registered Pharmacist (Rph) or Doctor of Pharmacy (PharmD)
• 3 years’ experience working in a health plan or Medicare provider with PGY1 residency or 5 years’ experience working in a Health Plan or Medicare Provider
• Licensed Pharmacist in good standing with the State of Alabama
• Good computer skills including Microsoft suite of products
• Ability to prioritize effectively and collaborate with all levels of associates
• Ability to interpret regulatory technical guidance and apply it to daily work
• Knowledge of Medicare Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

PREFERRED:

• Health care related degree or master’s degree (MBA, MSHA, MM, MPH, etc.)
• Experience in the RX Claims system
• Board Certified Specialist (BCPS, BCGP, etc.) and/or a health care related certification (ex: MTM certification)
• Knowledge of health plan pharmacy benefit administration processes