Clinical Staff Pharmacist

Clinical Pharmacist Role Summary:

Provides clinical review expertise for high dollar and complex pharmacy claims and may identify cases for potential fraud and abuse and makes referrals. This position is responsible for the supporting of formulary strategies involving both pharmacy and medical products, clinical actions following release of new/existing drug products, evaluating and managing drug utilization review, and pipeline product tracking and forecasting. Affordability solutions encompass activities that include utilization management edits at point of service, preferred drug list strategy, retrospective utilization review, risk management review and condition-specific interventions.

Responsibilities:

• Apply critical thinking to achieve proper clinical decisions when performing clinical reviews
  Utilize multiple systems and other clinical resources to achieve proper decisions in utilization management reviews
• Work and maneuver within queue systems that prioritize clinical reviews
• Be able to make a clinical decision quickly and decide and act with or without all information
• Evaluate opportunities for cross-benefit drug management in an integrated model
• Provide support to the condition-based program managers to enhance clinical affordability and total health outcome
• Evaluate the success of current utilization management program to determine areas of enhancement
• Review current utilization management strategies to ensure strategies promote affordability and customer experience
• Provide education and training for clinical team to communicate clinical strategy and actions and assure consistent execution of class strategy
• Examine egregious medications/products and coordinate with clinical program directors to provide appropriate clinical recommendations to minimize client and customer cost

• Work and collaborate with a multi-disciplinary clinical team to provide a customer centric experience
• Serves as a resource to facilitate understanding of medication related products
• Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally
• Adheres to quality assurance standards
• Excellent time management, organizational, and research skills

Qualifications

• PharmD or equivalent
• Licensed Pharmacist required
• Experience developing end to end Pharmacy Clinical Programs desired
• Minimum of 1 year Clinical Pharmacy experience required, preferably in a Pharmacy Benefit Management (PBM) or similar clinical practice environment
• Solid understanding of evidence based medicine, interpreting clinical literature, and standards of care required
• Demonstrated ability to work in a highly matrixed environment

• Experience with MS Office Suite (Outlook, Excel, Access, SharePoint)
• Excellent time management, organizational, and research skills
• Preferred: Utilization Review or Claim Review experience in Health insurance

About The Cigna Group