Job Description

Duties & Responsibilities:

• 95% - Pharmacy Management
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Generates and analyzes claims and utilization reports to track general trends in drug utilization and to identify potential targeted utilization management activities.
• Develops and updates drug utilization criteria.
• Develops and maintains contacts and relationships with providers key to successful interaction and intervention activities.
• Participates in medication review, disease state management and other clinical quality improvement programs such as Stars and Healthcare Effectiveness Data and Information Set (HEDIS) Quality Improvement Programs, Medication Therapy Management (MTM), interdisciplinary care teams and PACE.
• Assists the Pharmacy Director and the Manager of Clinical Pharmacists in the preparation of drug monographs and utilization reports for the Pharmacy and Therapeutics committee.
• Utilizes clinical and regulatory guidelines in the review of drug prior authorization and appeals requests.
• Adheres to regulatory compliance and quality guidelines policies and procedures.
• Updates pharmacy policies and develops new policies and procedures when needed.
• Works with management to recommend, develop and implement target drug utilization intervention programs and other Drug Utilization Review/Drug Utilization Evaluation (DUR/DUE) activities.
• Works with the Manager of Clinical Pharmacists and within Medical Management (e.g., with data manager, case managers, etc.) on various data integration, disease management and outcomes projects.
• Reviews members’ medication profiles and makes recommendations to health care providers based on evidence-based medicine and national guidelines for disease management as part of

polypharmacy program.

• Serves as the plan representative for state fair hearings.
• Resolves complaints, grievances and appeals.
• 5% - Other
• Completes other duties and projects as assigned.

Minimum Qualifications:

• Doctor of Pharmacy degree PLUS current knowledge and expertise in clinical pharmacology and disease states required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Preferred Qualifications:

• Experience in pharmacy practice or residency in pharmacy practice.
• Centers for Medicare & Medicaid Services (CMS), Department of HealthCare Services (DHCS), Department of
• Managed Health Care (DMHC) and/or National Committee for Quality Assurance (NCQA) audit experience.
• Bilingual in English and in one of defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).

Required Licensure / Certifications:

• A current, valid and unrestricted California state registered pharmacist license required.

Knowledge & Abilities:

• Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

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