Job description
Let’s do great things, together
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.
Currently, we are seeking a clinical pharmacist to support the accessibility, quality, and cost-effectiveness of our pharmacy benefits. This position focuses on initiating, supporting, and continuing cost-effective medication utilization strategies.
This is a remote position only for candidates living in OR, ID or WA.
Primary Functions:
- Perform coverage determinations (i.e., prior authorization reviews) and appeals requests for all lines of business (i.e., commercial, exchange, government) according to criteria guidelines and in compliance with Medicare, Medicaid, and state regulations.
- Develop and implement clinical utilization criteria for new market entries and market updates utilizing evidence-based medicine principles.
- Review, update, and maintain policies and procedures related to clinical pharmacy services.
- Provide concise, applicable, comprehensive, and timely responses to requests for drug information to members, clients, and providers.
- Analyze and monitor medication use through assessment of pharmacy claims data to develop clinical strategies to drive utilization towards high-value medications.
- Provide clinical support services including but not limited to benefit design, formulary analysis, drug information, P&T participation, clinical applications, client support, and drug utilization management.
- Act as a clinical leader across all operational units to deliver the highest level of care in regard to formulary management strategies.
- Prepare, implement, and maintain DUE, DUR, and QI programs to meet plan, HEDIS, and NCQA guidelines.
- Follow the company HR policies, Code of Conduct, and all department policies and procedures including protecting confidential company, employee, and customer information.
- Complete significant projects and performs all other related duties as assigned by the Director of Pharmacy and departmental managers
- Doctor of Pharmacy degree (Pharm.D.) preferred.
- Current active and unrestricted Oregon Registered Pharmacist license, or eligible for Oregon licensure which is to be obtained within 60 days of hire date.
- 2-3 years of managed care experience or training from an accredited managed care residency program.
- Proficient with Microsoft Word, Excel, Outlook, and PowerPoint.
- Strong analytical skills and business acumen.
- Advanced competency in literature evaluation.
- Ability to deliver high-quality evidence-based recommendations to internal and external medical providers.
- Strong written and verbal communication skills.
- Ability to communicate and present technical information in layman terms.
- Ability to work independently and collaborate cross-functionally with various stakeholders.
- Project management skills and the ability to plan and execute projects pertaining to formulary design and clinical programs.
- Ability to develop and conduct quality improvement initiatives to enhance the delivery of care and improve appropriate pharmaceutical utilization.
- Commitment to service, organization values, and professionalism through appropriate conduct and demeanor always.
- Ability to maintain confidentiality and project a professional business image.
- Works well under pressure with frequent interruptions and shifting priorities.
Benefits:
- Medical, Dental, Pharmacy & Vision
- 401K & FSA
- PTO and company paid holidays
Together, we can be more. We can be better.
Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law.
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