Prior Authorization Remote Pharmacy Jobs in Silver Spring, MD

Resp & Qualifications

PURPOSE: 

The Clinical Pharmacist will be part of the Quality/Stars Pharmacy outreach team plays a critical role in driving Medicare Advantage Star Ratings performing by improving key pharmacy quality measures, including medication adherence for chronic condition medications, statin use, polypharmacy safety measures. The pharmacist is responsible for executing targeted, data-driven outreach to members, providers, and pharmacies to address gaps in care and improve medication-related outcomes.

We are looking for an experienced professional to live and work remotely from within the greater Baltimore/Washington metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.

ESSENTIAL FUNCTIONS:

• Conduct outbound and inbound outreach to members to address medication adherence barriers and optimize therapy. Engage provider and pharmacies to resolve medication-related issues, including refills, reversed medications, therapy gaps, and clinical interventions. Educate members on medication use, adherence strategies, and disease state management. 
• Independently manage a daily work queue of prioritized outreach opportunities, ensure timely and effective completion of outreach, documentation, and follow-up activities. Demonstrate strong outcomes by consistently closing gaps and driving measurable results. 
• Provide clinical guidance and mentorship to pharmacy technicians supporting outreach, partner with cross-functional teams to optimize program performance. 
• Perform comprehensive medication and clinical reviews to identify opportunities for optimization, safety, and adherence. Support resolution of clinical and administrative barriers, including prior authorizations, formulary alternatives, medication access issues. 
• Identify and resolve social risk barriers impacting medication adherence, i.e. transportation challenges, cost of affordability concerns and access to care
• Continuously adapts outreach approach and clinical strategy based on real-time data and performance trends. 

Education Level: Ph.D: Pharmacy (Doctorate of Pharmacy)
Experience: 5 years experience in clinical pharmacy, preferably in a managed care environment.

Licenses/Certifications Upon Hire Required:

• PHARMD - Licensed Pharmacist Direct Patient Care - Active Registered Pharmacist in Maryland and/or DC.

Preferred Qualifications:

• Experience in Medicare and/or Medicaid
• Experience working in healthcare industry with a thorough understanding of prescription benefit management programs and practices. 

Knowledge, Skills and Abilities (KSAs)

• Self-starter with strong initiatives and ability to operate with minimal direction.
• Results-driven mindset with a focus on achieving measurable quality outcomes.
• Ability to prioritize work and manage a high-volume, dynamic workload.
• Excellent communication skills for engaging members and providers and having sometimes difficult conversations.
• Ability to work independently, as well as a member of a team.
• A strong balance between clinical expertise and business acumen.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: 120,240 - 214,929

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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