5 years of practice experience with a health plan pharmacy service, managed care environment, and/or retail or hospital pharmacy service
2 years of practice experience in developing and applying clinical drug use criteria
Required Education
Pharmacy degree from an accredited college of pharmacy
Required Licenses
Active, current and unrestricted State of Arizona (a state in the United States) pharmacist license
Required Certifications
N/A
Preferred Work Experience
Preferred Education
Doctor of Pharmacy (Pharm.D) degree
Preferred Licenses
Preferred Certifications
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES
Maintain medical drug authorization system functionality to ensure appropriate application of clinical criteria and adherence to regulatory requirements of the medical drug authorization processes and outputs.
Establish medical drug reporting to demonstrate operational productivity, clinical decision outcomes and assessments, and compliance with regulatory requirements such as case turn-around times (TAT) and outreaches for information and decision notifications.
Implement, maintain, and enforce policies and procedures for member medical drug authorizations and service requests in accordance with accreditation, state and federal guidelines and requirements
Serve as clinical reviewer for requests for medical drug services, appeals, expert opinion requests, and complex member cases
Develop and maintain medical drug, and pharmacy drug use criteria and protocols in collaboration with health plan pharmacists
Support health plan pharmacists and VP of clinical operations or CMO regarding clinical coverage criteria and criteria committee activities and decisions.
Create and maintain site for access of Medicaid Business Segment medical drug coverage criteria
Assist with the provision of accurate Medicaid Business Segment medical drug and clinical criteria documents as well as notices to providers and members on medical drug coverage and clini
Benefits
Health insuranceVision insuranceRemote work options
Additional Information
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:
Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week
Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week
Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month
Onsite: daily onsite requirement based on the essential functions of the job
Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building
Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.
This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.
PURPOSE OF THE JOB
Manages the medical drug benefit for Medicaid beneficiaries by implementing and managing the operations of the medical drug benefit and maintaining the medical drug coverage criteria and policies for the diverse Medicaid plans. Assist health plan pharmacists by creating and updating clinical criteria for medical drug coverage consistent with regulatory requirements and evidence based clinical practice, review requests for medical drug benefit services, and work to improve performance metrics associated with the medical drug authorization processes which include but is not limited to medical authorization case turn-around times, case decision integrity, operations best practices, efficient system configurations, and actionable reporting. Educate appropriate staff on medical drug authorization systems, application of clinical coverage criteria, and case outcomes as well as maintain appropriate documentation of systems and criteria for audit purposes. Complete projects assigned by Medical Services leadership and work with other health plan pharmacists with medical and pharmacy medication use projects as requested.
Bcbsaz · AZ Blue Phoenix, AZ 85021