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Clinical Pharmacist - Jacksonville, NC - Wellcare Health Plans

Company: Wellcare Health Plans
Location: Jacksonville
Posted on: November 10, 2019

Job Description:

Reviews Medicare and Medicaid members' claims history to ensure clinical appropriateness and optimum care while performing utilization management activities including dose optimization and formulary management for prior authorizations and coverage determination requests. Monitors quality of prior authorization and coverage determination requests for our Medicare and Medicaid lines of business. Monitors pharmacy performance to ensure all regulatory state and federal contractural requirements are met. Develops and maintains medication protocols and decision tools. Develops policies and procedures, present medication reviews at Pharmacy & Therapeutic Committee meetings and provides a source of drug information to WellCare associates, providers, and its members.Department: Pharmacy OperationsReport to: Corporate Medical DirectorLocation: Jacksonville, NC 28546Essential Functions:Reviews Medicare and Medicaid prior authorizations and coverage determination requests to ensure clinical appropriateness and optimization of care.Ensures associates handle prior authorization/coverage determination requests within all federal and state regulatory compliance time frames.Ensures associates apply departmental policies and procedures, clinical criteria justifications, and defined roles and responsibilities to prior authorization/coverage determination decisions and/or during inbound or outbound phone calls.Reviews pharmacy claims data to identify possible clinical savings opportunities.Presents medication reviews at Pharmacy and Therapeutics Committee meetings.Develops and maintains medication protocols and decision tools.Develops departmental policies and procedures in conjunction with all state, federal, and contractual requirements.Performs special duties as assigned.Education: A Bachelor's Degree in Pharmacy. A Pharm D preferred Experience: Previous clincal pharmacy support for pharmacy, DM programs, quality and UM. Exposure to managed care preferredLicenses/Certifications: Licensed pharmacist in state of operation Special Skills (e.g. 2nd language): Independence with regards to clincial discussions and evaluationsAbility to use pharmacetical and medical reference literature to provide drug information to the health plan, patients and prescribers.Technical Skills/Requirements:Use of Word, Excel and PowerPointAbout usHeadquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.

Keywords: Wellcare Health Plans, Jacksonville , Clinical Pharmacist - Jacksonville, NC - Wellcare Health Plans, Healthcare , Jacksonville, North Carolina

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