Job DescriptionFacilitates the company’s efforts in the development of pharmacy fraud, waste and abuse (FWA) programs. Supports FWA efforts by reviewing physician prescribing patterns, pharmacy dispensing patterns, and member utilization patterns to identify outliers using evidence-based best practices, conducts audits of pharmacies and pharmacy claims, works closely with internal staff in the refinement of the company’s pharmacy management solutions programs, providing consultation on pharmacy FWA issues to SIU personnel, . Primary activities center on discussions with pharmacies, SIU vendors, and customers regarding pharmacy procedural issues and the development and implementation of FWA controls. Coordinates with operations, clinical, medical, reporting and other internal departments as needed.
- Pharmacy Data Review: Regularly reviews and monitors prescription claims data and prescribing practices identified as outliers by internal and/or external analysis of pharmacy claims data. Assists in the definition of criteria for algorithms to detect pharmacy, prescriber or member FWA.
- Consultations/Interventions: Contacts pharmacies and prescribers identified as needing consultation to provide coaching on filling and prescribing practices that have been identified as outliers.
- Intervention Tracking and Documentation: Conducts and tracks investigation and audit steps per operations procedures. Documents content of and results of audits and investigations as defined in operations procedures; maintains records as required. Coordinates individual work activities with SIU Investigators, develops and presents findings and recommendations regarding the appropriateness of prescriptions, pharmacy claims, and supports overpayment recovery during discussions with providers. Presents findings and provides testimony in legal proceedings as required
- Intervention Refinements: Collaborates on the refinement of FWA interventions and controls; solicits and utilizes input from those contacted toward improvements. Educates pharmacy staff at all levels on federal and state statutory, regulatory and contractual requirements, appropriate billing according to guidelines, acceptable practice standards, and procedures for preventing and reporting potential fraud and abuse
- Operations: Contributes to the success of the operations of the pharmacy program by assisting with the implementation and management of both written and verbal communications to pharmacies and prescribers and maintenance of the edits and data elements that support the edits for FWA. Is available for consultation on pharmacy-related FWA questions. Presents educational seminars on fraud and abuse awareness, detection and reporting to areas and departments as required.
- Quality Improvement: Contributes to program improvements by being proactive in identifying improvement opportunities and by contributing on-going consultation and collaboration with product leaders and customers on FWA.
- Medical/Clinical: Upholds clinical integrity of pharmacy FWA program by staying up-to-date on medication information, contributing to the identification of pharmacy FWA program best practices, collaborating with Medical Directors, Medical Dept., and Clinical Dept. and provides pharmacy FWA expertise within the organization.
- Other duties as assigned. Contributes creative solutions to improve operational efficiency and effectiveness of pharmacy FWA team.
General Job Information
TitleSIU Clinical Pharmacist Reviewer - remote must be in California
Job FamilyPharmacy Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date10/29/2019
Date Requisition Created10/29/2019
EducationBachelors: Pharmacy (Required)
License and Certifications - RequiredRPH - Registered Pharmacist - Pharmacy
License and Certifications - PreferredPharmD - Doctor Of Pharmacy, State Licensure - Pharmacy
Other Job Requirements
Responsibilities5 years experience needed. Specialty pharmacy, oncology or other clinical pharmacy experience required. Managed pharmacy benefits organizations preferred.-Managed care experience preferred.-Experience with pharmaceuticals in a pharmaceutical sales, retail, or managed care environment, including contact with physicians/prescriberspreferred.-Management experience in the coordination of and collaboration of work teams preferred.
-5 yrs experience in clinical pharmacy with emphasis in specialty pharmacy and oncology.-Registration as a Pharmacist.-Managed care pharmaceutical service experience plus experience with coaching physicians and prescribers on medication issues, especially on specialty medications. -Knowledge of current research related to specialty medications.-Strong research and implementation skills in practical settings. -Analytic skills which can translate into practical and pragmatic recommendations. -Strong team orientation with respect for all members. -Strong verbal and written communications skills. -People skills are essential that allow for the successful consultation with physicians, prescribers and pharmacists and for successful collaboration with company employees and external vendors who do not directly report to this job. -Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
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