About this role
Your Role The Prior Authorization (PA) team utilizes clinical knowledge to review authorization requests for coverage under the outpatient pharmacy benefit. The Pharmacist-Consultant will work as part of the pharmacy benefit Prior Authorization (PA) team to support the Blue Shield of California (BSC) Pharmacy and Therapeutics Committee (P&T) by ensuring that evidence based clinical decisions are implemented appropriately to provide a high-quality and cost-effective pharmacy benefit. The Pharmacist- Consultant (Drug Utilization Review Pharmacist) will report to the Drug Utilization Review (DUR) Pharmacist Manager. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Work In this role, you will:
• Support the clinical and operational implementation of P&T approved policies for the pharmacy benefit, for both the Commercial and Medicare lines of business
• Apply clinical expertise to PA reviews and work collaboratively with the PA and Call Center Teams to support access to safe, efficacious, and medically necessary medications
• Operate in compliance with all regulatory and accreditation requirements to ensure all requests are reviewed within regulatory required timeframes
• Serve as a resource to internal and external constituents regarding the Blue Shield drug formulary, medication policies and appropriate drug use
• Embrace BSC values by answering clinical and operational questions, participating in group discussions, and supporting other team members while working towards a collective goal
• Use clear and concise communications and on-brand messaging when communicating with providers or members
• Follow all corporate policies and procedures
• Operate in compliance with all regulatory and accreditation requirements, and corporate policies and procedures regarding the support access to safe, efficacious, and medically necessary medications
• Assist in preparing materials for audits and reports; complete projects as assigned
Your Knowledge and Experience
• Requires a Doctor of Pharmacy (PharmD) degree
• Requires a currently active and unrestricted California Registered Pharmacist (RPh) license
• Requires at least 2 years of experience in clinical pharmacy
• Requires experience working at a health plan (managed care, government payer, or academic)
• 1 year of prior authorization experience required
• Experience working with formulary and medication policies required
• Excellent oral and written communication skills
• Thorough knowledge of therapeutic use of medications
Hybrid Virtual Work This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.