Clinical subject matter expert supporting formulary management, Pharmacy Benefit Manager (PBM) oversight, and pharmacy clinical programs across all lines of business.
Responsibilities
Perform clinical audits of initial and appeal utilization management determinations across all lines of business to evaluate clinical appropriateness, consistency, application of coverage criteria, and compliance with regulatory and organizational requirements.
Provide clinical oversight of delegated PBM utilization management and formulary activities, including monitoring performance, identifying trends or areas of concern, and recommending opportunities for improvement.
Provide oversight and coordination of Pharmacy & Therapeutics (P&T) Committee activities, including review of PBM recommendations, formulary decisions, clinical criteria, and implementation activities.
Monitor the clinical and financial impact of formulary strategies and utilization management initiatives, including member disruption, utilization trends, and overall program performance.
Provide personalized member counseling and assistance related to formulary changes, medication access, therapeutic alternatives, and other medication-related needs.
The Clinical Pharmacist – Formulary & PBM Oversight serves as a clinical subject matter expert supporting formulary management, Pharmacy Benefit Manager (PBM) oversight, and pharmacy clinical programs across all lines of business.
Responsibilities
Perform clinical audits of initial and appeal utilization management determinations across all lines of business to evaluate clinical appropriateness, consistency, application of coverage criteria, and compliance with regulatory and organizational requirements.
Provide clinical oversight of delegated PBM utilization management and formulary activities, including monitoring performance, identifying trends or areas of concern, and recommending opportunities for improvement.
Provide oversight and coordination of Pharmacy & Therapeutics (P&T) Committee activities, including review of PBM recommendations, formulary decisions, clinical criteria, and implementation activities.
Monitor the clinical and financial impact of formulary strategies and utilization management initiatives, including member disruption, utilization trends, and overall program performance.
Provide personalized member counseling and assistance related to formulary changes, medication access, therapeutic alternatives, and other medication-related needs.
