Clinical Advisor

Job Summary:

The Clinical Advisor is responsible for utilizing pharmacy acumen, medication expertise, and healthcare payer knowledge related to drug-related prior authorization requirements and medication guidelines to support PA operations (in completing PA reviews), PA technology and automation, consultation on evidence-based guidelines and pharmacy policy, reporting and analytics, and quality management programs. The Clinical Advisor will collaborate with a team of pharmacy technicians and pharmacists in Pharmacy Operations.

Job Responsibilities (but not limited to): [PHARM Core 25 (d)]

• Serves as a subject matter expert in the development and maintenance of drug formularies and

clinical programs.

• Works with stakeholders to understand client’s product-specific requirements and configuration

needs and translate them into technical design specifications and data flow for development,

coding, and configuration.

• Coordinates activities as part of the Formulary Development and Maintenance team and

recommends measures to improve performance and efficiency.

• Manage operations of the Pharmacy & Therapeutics (P&T) Committee including scheduling drug

class reviews, reviewing new branded agents, coordinating internal/external membership,

documenting P&T minutes, and preparing and organizing P&T files.

• Conducts and evaluates research necessary for the development of utilization management

strategies.

• Performs clinical reviews of PA, Step Therapy, Quantity Limit, and all other pharmacy utilization

requests in accordance with quality, timeliness, and efficiency standards.

• Performs coverage determinations and appeals requests according to criteria guidelines and in

compliance with all state and federal regulations, including Medicare and Medicaid.

URAC Compliance: Pharmacy Core v3.2: PHARM Core 25

JOB DESCRIPTION

• Takes calls from internal and external stakeholders as it pertains to the PA process, answering in

a timely, accurate and professional manner.

• Researches and appropriately responds to PA guideline coding and rationale questions.

• Develops and implements clinical utilization criteria for new market entries and market updates

utilizing evidence-based medicine principles.

• Makes strategic recommendations including benefit design and formulary analysis, provision of

clinical drug information, Pharmacy & Therapeutics support and participation, rational drug

formulary positioning, online system edits and restrictions, ongoing clinical product evaluations,

and client pharmacy benefit utilization and performance trends as required.

• Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical,

financial, and operational effectiveness and quality.

• Provides support for internal and external audits and surveys.

• Supports Fraud, Waste and Abuse (FWA) program system oversight and communicates any

suspected fraud discovered.

• Assures compliance with RxAdvance policies and procedures.

• Has a thorough understanding of and performs in compliance with the current URAC and NCQA

standards applicable to the position.

• Stays abreast of new regulations to ensure regulatory compliance of PA guidelines.

• Maintains privacy and confidentiality in all PA or appeal request interactions.

• Follows all state and federal regulations applicable to PBM operations and utilization

management.

• Other duties as assigned.

Qualifications: [PHARM Core 25 (a) (b) (c)]

1. Education and/or Training:

• Bachelor’s degree in pharmacy or related fields required.

• Doctor of Pharmacy (PharmD) degree from an ACPE accredited college is preferred.

• Managed Care or Clinical Residency program residency highly preferred.

2. Professional Experience:

• At least 1 year of recent managed care experience in a PBM or health plan setting.

• Experience with Medicare Part D highly preferred.

• Must have a regard for confidential data and adherence to corporate compliance policy.

• Expert knowledge of the principles and practices of pharmaceutical science, a working

knowledge of managed care and policy development as well as working knowledge of state and

federal controlled substances and related laws, rules, and regulations.

• Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology.

3. Licenses/Certifications:

• Registered and in good standing with the Board of Registration in Pharmacy.

URAC Compliance: Pharmacy Core v3.2: PHARM Core 25 Page 3 of 3

JOB DESCRIPTION

• Active, non-restricted pharmacist license.

4. Specialized Skills:

• Strong clinical review competency.

• Requires a high degree of initiative and excellent judgment to make decisions regarding clinical

pharmacy issues in an extremely complex and often politically charged environment.

• Requires excellent analytical skills necessary for program implementation, maintenance and

enhancement and ability to analyze, assess and monitor physicians' prescribing trends and drug

utilization patterns for clinical appropriateness and cost-effectiveness with the Plan's operations

and goals.

• Highly developed oral/written communication skills, self-motivation, and ability to work

independently with minimal supervision are necessary.

• Must be flexible and able to constantly review and reset priorities, often daily, and to handle

multiple projects simultaneously.

• Must be able to appropriately identify emergency situations and follow through with the

appropriate protocol.

5. Technical Skills:

• Strong PC skills; MS Word, Excel, Access, and Power Point.

6. Additional Considerations:

• Applicants must be able to pass a background investigation as all offers are pending successful

completion of background check per the company policy.

Physical and Mental Requirements:

1. Physical Activities:

• Some travel may be required.

2. Mental Activities:

• General mental activity related to job duties.