Job Description

Job Description

Job Description

UNITE HERE HEALTH serves over 200,000 workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!

The Clinical Pharmacist aims to enhance healthcare value, reduce costs, and ensure high-quality pharmaceutical care for UNITE HERE HEALTH’s internal Pharmacy Benefit Manager (PBM) members by performing daily clinical pharmacy tasks related to prior authorization. This role provides vital support to the PBM and is focused on supporting clinical programs and utilization management. Responsibilities in utilization management include reviewing prior authorization requests to assess drug therapy based on member benefits and coverage criteria, developing and maintaining pharmacy and medical drug therapy guidelines, creating clinical criteria for formulary exceptions and prior authorization requests, and managing prescription limitations (such as age, gender, and quantity). Additional responsibilities involve supporting clinical programs like disease management, care management, and drug management initiatives.

ESSENTIAL JOB FUNCTIONS AND DUTIES

• Evaluates formulary exception and prior authorization requests, making decisions for drug products based on member benefits, established treatment protocols, and clinical criteria
• Conducts research on drug information to stay updated on drug knowledge and disease states, ensuring effective application during formulary exception and prior authorization reviews
• Provides input for the development of clinical content of new programs and for maintenance of existing programs
• Provides recommendations for enhancing medication edits (e.g., programming) and coverage criteria, based on utilization data and insights gained from coverage determination reviews
• Makes coverage determinations within the defined turnaround times and to meet regulatory requirements
• Collaborates with the pharmacy director to research and synthesize detailed clinical data related to pharmaceuticals to identify opportunities for improving quality or overall cost
• Supports medical cost management, utilization management and medication management initiatives, projects, and related activities
• Supports Hospitality Rx’s efforts around researching, developing, and revising pharmacy and medical coverage guidelines
• Assists in the development of clinical criteria for the Pharmacy and Therapeutics Committee; participates in support of the Pharmacy and Therapeutics Committee
• Assists in Hospitality Rx’s efforts to develop and design clinical edits to adjudicate claims and enhance drug utilization
• Performs comprehensive and targeted medication reviews to identify, resolve, and prevent medication-related problems for targeted members
• Provides clinical guidance and support
• Utilizes prescription and medical claims data to generate clinical recommendations
• Serves as pharmacy subject matter expert (SME) on projects; support internal business partners such as care/case managers, health promoters and member services
• Provides internal professional staff and external member and provider education related to pharmaceuticals, disease states and program interventions
• Collaborates with pharmacy director to help with workflows and operational efficiencies
• Reviews and resolves complaints made by member and providers regarding formulary exception, prior authorization, formulary, or pharmacy services
• Assists in training and mentoring new hires
• Set goals and achieve measurable results
• Contributes ideas to plans and achieving department goals
• Exemplifies the Fund’s values in contributing to a respectful, trusting, and open culture of inclusion and engagement
• Performs other duties as assigned within the scope of responsibilities and requirements of the job
• Performs Essential Job Functions and Duties with or without reasonable accommodation

ESSENTIAL QUALIFICATIONS

Years of Experience and Knowledge

• 5 ~ 7 years of direct experience minimum
• 0 ~ 2 years of experience in a managed care environment or clinical management role preferred

Education, Licenses, and Certifications

• Bachelor's degree in Pharmacy with optional post-graduate training or related field or equivalent work experience required
• Doctor of Pharmacy (PharmD)
• Required: Active, unrestricted, Illinois pharmacist license

Skills and Abilities

• Knowledge of PBM industry, formulary management, pharmacy claims and managed care principles and practices
• Analytical, research and development skills
• Communication skills (written and verbal)
• Organizational, team, deductive reasoning, problem solving, and decision-making skills
• Ability to work collaboratively with all levels of staff
• Ability to provide effective leadership to pharmacy technicians
• Proficient in Microsoft office Suite with emphasis on Microsoft Excel, MS Word, and Power Point including tables, charts and figures preferred
• Strong clinical skills and the ability to exercise sound clinical judgment across a range of situations are essential
• Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
• Capability to analyze and convert clinical information into a format suitable for clinical systems for both clinical and non-clinical audiences
• Demands careful attention to detail to ensure projects are clinically, editorially, and systemically accurate and can be effectively implemented

Salary range for this position : Salary $137,200 - $174,900. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) as a hybrid / work-from-home arrangement.

We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Pension, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).

#LI-Hybrid

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