Managed Care Clinical Pharmacist - Community Health Choice
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements
JOB SUMMARY:The Clinical Pharmacist provides highly specialized integrated clinical pharmacy services to the health plan. The Pharmacist will provide drug utilization reviews based on establish protocols for prior authorization and appeal requests, and to provide educational outreach to prescribers as appropriate.
The Managed Care Clinical Pharmacist will assist with:
- Developing prior authorization review criteria for medications covered on pharmacy and medical benefits
- Conduct oversight over prior authorization criteria and delegated utilization management functions performed by PBM
- Reviewing PBM's formularies to identify improvement opportunities
- Create and refine policies and standard operating procedures for pharmacy operation processes
The Pharmacist may be responsible for other functions as assigned to ensure quality care for members while meeting expectations for prescription drug cost containment; and assisting with the development of clinical initiatives that support the processes of prior authorization, plan designs, formulary management, provider/member communication, retrospective drug utilization review and clinical consultation with members and providers.
1. Education/Specialized Training/Licensure:
- Bachelor's Degree in Pharmacy required;
- PharmD preferred.
- Must be a Texas registered pharmacist
2. Work Experience (Years and Area):
- 2 year of applicable experience as a registered pharmacist with managed care experience.
- Experience with prior authorization management.
- Medicare, Medicaid, and Marketplace experience with a Health Plan or PBM preferred.
3. Management Experience (Years and Area): N/A
4. Software Operated: Microsoft Office (Word, Excel, Outlook)
SPECIAL REQUIREMENTS: (Check Applicable Areas)
1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Exceptional Verbal (e.g., Public Speaking)
Writing /Composing: Correspondence / Reports
2. Other Skills:
3. Advanced Education:
Advanced Training Specialty: Completion of a pharmacy residency is strongly preferred.
Bachelor or Doctor of Pharmacy degree from an accredited school of pharmacy required
4. Work Schedule: Flexible
RESPONSIBLE TO: Vice President
EMPLOYEE SUPERVISED: None