Note: The job is a remote job and is open to candidates in USA. Blue Cross and Blue Shield of Nebraska is a mission-driven organization dedicated to championing the health and well-being of its members and communities. The Clinical Pharmacist will be the expert on clinical issues, responsible for designing and implementing pharmacy-related utilization management programs, maintaining URAC accreditation, and supporting Medicare Advantage processes.
Responsibilities
- Create and Maintain Clinical Criteria for applicable Utilization Management (UM) programs: Develop and maintain clinical criteria (access to Prime standard and BCBSNE specific versions); Develop and maintain criteria process flows; Develop and maintain physician fax forms and other modes of communication; Utilize predictive modeling tool to intervene with high-risk members for identified disease states; Provide clinical updates as necessary to internal staff and physician reviewers; Performs highly complex research, analysis and develops recommendations for UM programs & plan design changes
- Responsible for Operational workflows and Completion of UM reviews: Clinical oversight of first level review process; Clinical review of utilization management reviews; Perform clinical support for Pharmacy Technician and other staff; Utilize reporting tools to create efficiencies by reviewing medical and pharmacy claims data; Support physician reviewers with information required to efficiently review non-approvable claims; Develop Decision Tree review process when applicable
- Maintain URAC accreditation: Work with internal staff to ensure that URAC accreditation is maintained; The pharmacist will work within their scope of licensure and unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting drug utilization review. The clinical pharmacists may not conduct peer clinical review non-certifications for drug utilization management, if prohibited by state utilization management laws. The clinical pharmacists may not conduct peer clinical review non-certifications for drug utilization management if the requesting party specifically requests a clinical peer. Measure quality assurance reporting, turnaround time for urgent and non-urgent reviews and quantitative assessment of UM reviews by program
- Support Medicare Advantage processes, outreach, presentations, and tasks that require clinical direction and support. This includes, but not limited to, clinical presentations to internal and external stakeholders, providers, provider offices, and other customers
Skills
- Doctor of Pharmacy required from Accredited US College of Pharmacy
- An active, current, and unrestricted license or certification to practice pharmacy in Nebraska within 6 months of hire
- Experience with PBM operations, Medicare Advantage, and/or clinical program development and maintenance
- Managed Care Pharmacy Residency or 3-4 years of experience in Managed Care Pharmacy industry
Company Overview