Managing Clinical Pharmacist- Pharmacy Claim Audit amp Review

Profile

Description

The Managing Clinical Pharmacist within the Pharmacy Claim Audit & Review department monitors drug development pipeline, and medical literature, while providing clinical and audit support for internal stakeholders. Utilizes broad understanding of managed care and PBM knowledge to develop, and/or implement strategies and programs to mitigate cost trend. The Managing Clinical Pharmacist - Pharmacy Claim Audit & Review will manage a team of 8-10 auditors to ensure claims are paid correctly and pharmacies are dispensing appropriately. The manager will use independent judgment requiring analysis of variable factors to solve moderately complex problems; collaborate with management and top professionals/specialists in selection of methods, techniques, and analytical approach for audits.

Responsibilities

The Managing Clinical Pharmacist develops, maintains, and/or operationalizes audit processes related to coverage, Point of Sale edits, or clinical coverage policies for pharmacy and medical administered drug products. Conducts claims analysis on drug utilization trends to evaluate and inform formulary strategies.

Collaborates with management and top professionals/specialists in selection of methods, techniques, and analytical approach to support data modeling and querying. Collaborates on audit projects and develops proposals for audit projects. Supports trend by conducting analysis of audit outcomes. Performs escalated or more complex work of a similar nature, and manages a group of 8-10 auditors and support associates and audit initiatives throughout the department; coordinates and provides day-to-day oversight of associates and inventory. Ensures consistency in execution across teams and audit vendors. Holds team members accountable for following established policies.

Additional Job Duties:


New audit initiative research and implementation
Provide professional clinical guidance on audit reviews, including appeals and audit vendor findings
Review of new legislation to determine audit impacts
Litigation and complaint support
Represent Audit in collaboration with other departments on drug trend and drug utilization
Support FWA initiatives; consult with Lead Investigator and other investigative teams
Support and/or represent Pharmacy Claim Audit & Review with CMS audits and new guidance


Required Qualifications


Three years of leadership experience
Registered pharmacist;
An active, unrestricted Pharmacist license with the Board of Pharmacy in your state(s) of practice
Moderate business and financial acumen
Strong track record of driving solutions that achieved financial outcomes
Experience with effectively coaching, developing and leading direct reports and cross-functional teams
Excellent communication skills, both oral and written
Proficiency in Microsoft Word, Excel, & PowerPoint
Expertise in working collaboratively and communicating with staff in different positions and all levels of management positions
Experience working with CMS guidelines and Medicare Advantage


Preferred Qualifications


Pharm D
Master's Degree in Business Administration or a related field
Experience with pharmacy benefits and health benefits
Experience with Hospice
Experience working in a Clinical, Long Term Care or Inpatient hospital setting


Additional Information

Work-At-Home Requirements


WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information


Vaccination Info

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Scheduled Weekly Hours

40

Company info

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