Job Description

Your Role

The Pharmacy Services Drug Utilization Management team provides efficient and accurate responses to external customer (physicians, office staff, pharmacy providers, members and brokers) and internal team members for all outpatient medical benefit inquires . The Pharmacist, Consultant will report to the Manager of Medical Benefit Drug Utilization. In this role, you will support the Blue Shield of California Pharmacy and Therapeutics (P&T) Committee process and support the clinical components of the Pharmacy Services Drug Utilization Program by ensuring that evidence based clinical decisions of the Blue Shield of California Pharmacy and Therapeutics Committee are implemented operationally in order to support safe, efficacious, and cost-effective prescribing of medications provided under the medical benefit.

Your Work

In this role, you will:

• Provide pharmacotherapy expertise for Blue Shield’s pharmacy program by supporting: Pharmacy and Therapeutics Committee, drug formulary, drug prior authorization and utilization review programs, health plan benefit design, member/provider communications related to medication use, and the pharmacy student/residency programs
• Operate in compliance with all regulatory and accreditation requirements, and corporate policies and procedures regarding to support access to safe, efficacious, and medically necessary medications 
• Assist in preparing materials for audits and reports; complete projects as assigned
• Support the operational and clinical implementation of medication policies for drugs provided under the medical benefit, for Commercial, Medicare, and Medi-Cal lines of business
• Support the peer-to-peer process and facilitate provider discussion regarding prior authorization denials
• Provide pharmacist support for the drug prior authorization program by providing clinical expertise to Prior Authorization technician team to ensure review of prior authorization requests within regulatory required time frames
• Provide clinical and operational expertise in post service requests, completed within regulatory required timeframes
• Ensure compliance with various regulatory and quality accreditation requirements around drug utilization management in order to support safe, efficacious, and cost-effective prescribing
• Serve as an educational resource to internal and external constituents regarding the Blue Shield drug formulary, medication policies and appropriate drug use 

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
• Prior experience in managed care/PBM is preferred
• Requires working at least one weekend per month and company holidays as needed to ensure regulatory compliance with prior authorization turnaround times
• Thorough knowledge of therapeutic use of medications
• Excellent oral and written communication skills

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