Description
Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team.
Network Health is seeking a pharmacist - utilization management. This individual will oversee the administration of the pharmacy department's utilization management program for both traditional pharmacy and infusion-related medications.
Provides clinical support for other departments quality and health management efforts. Assists in the development and evaluation of the plan formulary and benefit designs.
Job Responsibilities :
- Administrative / Operational Support
- Compliance Regulatory
- Professional Collaboration Support
- Quality Outcomes (including Medicare Stars, NCQA, HEDIS)
- Support / administer vendor oversight audits
- Participates in case management, disease management and poly-pharmacy for Network Health patients with extraordinary high drug costs.
- Collaborates with formulary management team in development of utilization management criteria for Plan drug benefits. This will include incorporating rebate optimization, branch logic, automation, and machine learning where appropriate.
- Assists with operational oversight of Medicare Part D Fraud, Waste & Abuse Program and other government programs
- Pharmacy benefit utilization and prior authorization real-time surveillance
- Assists in tracking the introduction of generic drugs / biosimilars to the marketplace and develops focused projects / programs to maximize the cost-saving potential of these drugs and reduce costs in specific drug categories of the Plan formulary.
- Performs retrospective reviews / audits on claims and prior authorizations for appropriateness
- Assisting Sales, Member Experience, Providers, Brokers, and Community Partners with Pharmacy Benefit questions.
- Assists in tracking the introduction of new drugs to the marketplace and advises the Pharmacy and Therapeutics (P&T) Committee on formulary decisions.
- Performs other duties and responsibilities as assigned.
Job Requirements :
- Bachelor of Science in Pharmacy.
- A minimum of 3 years clinical experience.
- Residency / fellowship preferred.
- Managed care experience desirable.
- Current licensure without restriction by the State of Wisconsin Pharmacy Examining Board
This position will be required to work out of the Menasha (corporate) office daily.
We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.
Pharmacist - Utilization Management
Network Health is seeking a pharmacist - utilization management. Collaborates with formulary management team in development of utilization management criteria for Plan drug benefits. This individual will oversee the administration of the pharmacy department's utilization management program for both ...
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