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Department

*Remote Opportunity. Must be a Colorado Resident

Job Summary

The Clinical Pharmacist for Managed Care will report to and operate under the direction of pharmacy leadership and will be expected to work cooperatively and sometimes independently with all medical directors, utilization management nurses, and health plan personnel to improve the overall health outcomes of our members. They will need to perform prospective and/or retrospective drug utilization reviews and appeals per State and Federal regulations, participate in the distribution of clinical drug information, and educate providers and staff regarding the use of pharmaceutical treatment regimens or requirements. They must also comply with all company standard operating procedures, policies, guidelines, and work instructions. In addition, participation in Interdisciplinary Care Team (ICT) meetings, Medication Therapy Management (MTM) efforts, and Pharmacy & Therapeutics Committee may be asked of this role.

Essential Functions:

• Uses clinical knowledge and independent critical thinking skills toward interpreting criteria, policies, and procedures to make determinations on prior approval reviews and retrospective reviews or appeals.
• Assist in the completion, development, and supervision of support staff for the drug utilization and prior authorization review programs.
• Identifies, develops, and maintains clinical criteria for prior authorizations and step therapy for designated lines of business.
• Work with pharmacy leadership to ensure compliance with State and Federal pharmacy regulations for Medicaid, Medicare, and Commercial Lines of business.
• Develop, implement, and manage pharmacy cost containment strategies, including high-risk, high- cost, and high-use medications, to determine the most appropriate medication use management strategy for identified medications.
• Evaluate and identify opportunities for improved management of drug benefits through clinical research and analytics that improve medical/pharmacy cost savings and provide clinical quality initiatives.
• Actively work to support the preparation and delivery of reporting and meeting materials.
• Serve as a liaison to individual pharmacists, pharmacies, internal committees, case management, medical management, and other providers on pharmacy issues.
• Work with the clinical and operations staff of all vendors of pharmacy programs, including support to internal operational departments on implementing various PBM programs.
• Participate in the Interdisciplinary Care Team (ICT) meeting and collaborates with Complex Case Management (CCM) and Utilization Management (UM) on care coordination for high-risk members.
• Participation in Medication Therapy Management (MTM) efforts when required.
• Participate in the activities of the Pharmacy & Therapeutics Committee, including clinical and financial reviews of individual drugs, drug classes, formulary development, and development of clinical policies and related metrics.

Education:

• Bachelor's Degree BPharm, required OR
• Doctorate Degree PharmD (preferred)
• Colorado Pharmacist License Required

Work Experience:

• RPh or PharmD degree with at least 1-3 years of pharmacy, managed care, and/or pharmaceutical industry experience.
• Requires a functional level understanding of the pharmacy industry, including health plan/PBM relationship and drugs paid for on the medical vs. pharmacy benefit.

Licenses:

• PHA-Licensed Pharmacist - DORA - Department of Regulatory Agencies

Knowledge, Skills and Abilities:

• Excellent verbal and written communication skills with the ability to communicate and collaborate effectively with all internal stakeholders.
• Strong interpersonal, consultation, organizational, tracking, and follow-up skills.
• Data review and interpretation skills are preferred to identify and resolve drug-related problems and trends.
• Ability to work as a team member.
• Strong organizational skills and attention to detail.
• Ability to instruct, direct, and evaluate employees- will be required to assume responsibility for daily PA operations.
• Ability to work independently and with little supervision.
• Prior experience and/or knowledge of process improvement practices
• Proficiency with Epic, preferred but not required
• Proficiency with MS Office, required.

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program 

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver's 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado's primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).

Denver Health values the unique ideas, talents and contributions reflective of the needs of our community. For more about our commitment to diversity visit: https://www.denverhealth.org/for-professionals/careers/diversity-and-inclusion