Number of Applicants
:000+
JOB SUMMARY
This job works in a team oriented environment monitoring FDA-approvals, drug manufacturer pipelines, and assess drug utilization reports, in order to develop and execute the the Organization's Drug Formulary, and/or recommend codes for pharmaceutical based reporting. The incumbent may write drug monographs for Committee review; develops and implements the Organization's management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling, pharmacy policy review and development and/or review of member specific information to improve individual outcomes as an adjunct to health coaching. If acting in the capacity as a clinical pharmacist the incumbent may also review UM requests; provide consultation into the case and disease management identification process, and consult with the Organization's Associate Medical Directors and Medical Directors when appropriate, follow-up on appeals in accordance with our regulatory guidelines. The incumbent develops and implements physician, pharmacy, account, and member educational initiatives that promote the Organization’s Formularies, utilization management programs, and case/ disease management initiatives; providing clinical review and decisions for physician and member appeals and participates on cross-functional committees to develop and implement clinical and operational initiatives.
ESSENTIAL RESPONSIBILITIES
QUALIFICATIONS
Required
Preferred
SKILLS
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Rarely
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( )
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