Health Plan Clinical Pharmacist II

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.  

Position in this function is under the supervision of the Part D Pharmacy Manager - Health Plan Services, this position is primarily responsible for performing and/or supervising pharmacist activities related to all Pharmacy Quality Initiatives (i.e. RxQI, MTMP, Adherence, Hospital Discharge Prgm, Fraud Waste and Abuse monitoring, Part D coverage determination and appeals processing) for Kelsey-Seybold Clinic and/or KelseyCare Advantage. This position will oversee program staff as well as monitor and report ongoing progress of pharmacy quality initiatives. This position will also perform operational maintenance and/or implementation of new clinical services as well as any additional duties deemed necessary for the Pharmacy Services Department.

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.  

Primary Responsibilities:

• 40% Responsible for conducting clinical pharmacy services through Pharmacy Quality Initiative Programs. During these encounters with members the following will be conducted:  review of all current medications, review pharmacy claims in contracted PBM systems, drug-drug interactions screened, therapeutic alternatives recognized, communication with physician regarding drug therapy, patient counseling, medication reconciliation within EPIC (medical chart) and follow-up with member
• 10% Answer inbound calls and conduct outbound calls regarding processing of coverage determinations. Review medical information essential for coverage determination to be conducted.  Properly enters data into software program(s). Enter overrides in appropriate systems to process payment. Generates letters and/or reports. Works all appropriate program workflow steps and queues as assigned.  After hours/weekend coverage as assigned.  
• 10%    Communicate with physicians and other healthcare personnel to discuss specific medication recommendations, therapies for cost-effective care, general drug information, and educate about health plan prescription drug benefits
• 10% Monitors and evaluated claims for appropriate use by members, physicians and pharmacies.  Conducts drug utilization review of potentially fraudulent claims, abuse, and/or waste. Assists in reviewing claims adjudicated by the PBM to ensure payment for formulary products are processed correctly. Perform audits. Reports risks to management
• 10% Communicates instructions to internal and external individuals and/or departments. Furnishes and obtains information from other entities/vendors. Maintains staffing and program schedules
• 10%    Assists in the development of clinical pharmacy program enhancement and better practices within the department including but not limited to RX Quality Initiative (RXQI), Pharmacy Quality Initiative Programs (QIP), Adherence Programs, Medication Therapy Management Program (MTMP), Hospital Discharge Program (HDP), Fraud Waste and Abuse (FWA) protocols, and Coverage Determination (CD) processes
• 5% Provide program training and oversight. Provide training and oversight of program staff, pharmacy residents and assigned interns as needed. Assists in scheduling of Health Plan Pharmacy Services Department personnel to ensure program productivity. Monitor daily duties and program work queues to ensure program requirements and department goals are achieved. Create program reports weekly, monthly, quarterly, annually or upon request from management. Communicate program and staff concerns to management
• 3% Provides clerical support for Part D duties and audits. Provides administrative and clinical support for special projects. Responsibilities include attending and scheduling meetings, calendar management, dictation, answering phones and routine questions
• 2% Ensures prompt and courteous customer service by all Health Plan Pharmacy Services personnel. Responsible for compliance to federal and state Pharmacy laws. Triages patient emergencies and provides the appropriate follow up as needed. Responsible for adherence to federal and state Pharmacy laws

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Pharm D. degree
• Current and Active Pharmacy License
• TSBP Registered Pharmacist
• 3+ years operational pharmacy benefit experience, clinical and/or retail pharmacy experience
• Customer Service Experience
• Proficient with computer applications that include, but are not limited to: Microsoft Word, Excel, and Access
• Proven ability to communicate verbally and in writing with Health Plan Pharmacy Services Department personnel to delegate duties, inform about policies and assist in training
• Proven ability to communicate with physicians and other healthcare personnel to discuss specific medication recommendations, therapies for cost-effective care, general drug information, and educate about health plan prescription drug benefits
• Proven ability to communicate verbally and in writing with members/patients/vendors to handle complaints and problems, assist with questions, and recommend products/recommendations
• Proven to write reports (i.e., weekly/monthly), maintain audit logs, perform oversight and communicate concerns
• Proven good Alpha/Numeric data entry skills with minimal errors
• Demonstrates solid multitasking, problem solving & analytical skills
• Proven ability to lead others on team
• Proven detail oriented with good verbal and written communication skills, interpersonal skills, professional appearance, and ability to work effectively in a fast paced work environment
• Proven ability to communicate with all levels of the Management
• Proven excellent organizational skills
• Proven high Stress Tolerance

Preferred Qualifications:

• Completion of a Managed Care Pharmacy Residency Program or Pharmacy Practice Residency Program (PGY1)
• ASHP Immunization Certification
• BLS CPR Certification
• 3+ years of HMO 3rd party managed care experience
• 3+ years of Medicare Part D experience
• Experience with prior authorization, coverage determination and appeals processing
• Experience with vendor relations
• Customer Service experience
• Auditing experience
• Supervisory or management experience
• Knowledge of Medicare regulations with emphasis on Part D formulary, coverage determination and appeals processing
• Knowledge of the Pharmacy Benefit Management (PBM) industry
• Knowledge of Medicare 5-star ratings and HEDIS measures
• Staff Management

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $112,700    to $193,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.