Clinical Pharmacist

Job Description Job Description Clinical Pharmacist Location: Birmingham, AL 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 - Job Description The Clinical Pharmacist will provide leadership at the health plan in regard to clinical pharmacy decisions and programs. This individual will serve as the primary clinical reviewer for the Plan’s coverage determinations and appeals and grievances (CDAG), which may apply to Medicare or Commercial business and drugs covered under the medical or pharmacy benefit. This position 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 supporting Pharmacy Department efforts towards attainment of a minimum 4 Star CMS Medicare Advantage Plan Star Rating when supporting the Medicare line of business. Key Responsibilities 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 Department Management or Medical Directors if required. Assist with development and maintenance of coverage determinations decision flow charts to assist with review application and ensure processes are carried out in accordance with CMS and other regulatory requirements. Participate in on-call rotation for coverage determinations to satisfy regulatory requirements, including periodic weekend and holiday work as needed. 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, physician and member communications (one-one or general), programs in conjunction with internal or external stakeholders, and benefit/formulary adjustment recommendations. Assist with clinical oversight of PBM administration of formulary, utilization management criteria, and tools and platforms. Attend and prepare clinical updates for the Plan’s oversight committees as needed. 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 regulatory reviews and quality initiatives as needed. Work closely with the Pharmacy department to ensure a common understanding of all programs and interventions to ensure they are properly communicated and implemented. Participate in Pharmacy Student mentoring, education, and development as needed. REQUIRED QUALIFICATIONS : Registered Pharmacist (Rph) or Doctor of Pharmacy (PharmD) Licensed Pharmacist in good standing with the State of Alabama Excellent oral and written communication skills 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 PREFERRED QUALIFICATIONS: ~3 years’ experience in coverage determinations, health plan, or pharmacy benefits management and/or a managed care pharmacy residency ~ Knowledge of coverage determinations and appeals & grievances ~ Knowledge of health plan pharmacy benefit administration processes