Reviews Medicare and Medicaid members' claims history to ensure clinical appropriateness and optimum care while performing utilization management activities including dose optimization and formulary management for prior authorizations and coverage determination requests. Monitors quality of prior authorization and coverage determination requests for our Medicare and Medicaid lines of business. Monitors pharmacy performance to ensure all regulatory state and federal contractural requirements are met. Develops and maintains medication protocols and decision tools. Develops policies and procedures, present medication reviews at Pharmacy & Therapeutic Committee meetings and provides a source of drug information to WellCare associates, providers, and its members.
Report to: Dir, Pharmacy Operations
Position Location: Camelback Rd Phoenix, AZ 85016
Education: A Bachelor's Degree in Pharmacy. A Pharm D preferred
Experience: Previous clincal pharmacy support for pharmacy, DM programs, quality and UM. Exposure to managed care preferred
Licenses/Certifications: Licensed pharmacist in state of operation
Independence with regards to clincial discussions and evaluations
Ability to use pharmacetical and medical reference literature to provide drug information to the health plan, patients and prescribers.
Use of Word, Excel and PowerPoint