Pharmaceuticals Liaison

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Pharmaceuticals Liaison

Department: Health Care Services

FLSA: Full time, Exempt

Salary level: 5

Position Summary:

The Pharmaceutical Liaison is primarily responsible for interpretation and application of his/her knowledge in pharmacy-related matters and the health care services’ department’s interactions with its members, providers, and community partners. By leveraging this knowledge and independent analysis, this position plays a critical role in ensuring UHA members manage their chronic diseases by maintaining medication compliance, adherence to safety standards associated with those medications, and uses critical thinking and pharmacy expertise in all duties and responsibilities.

Provides independent judgement and discretion regarding integrated support to patients, providers, and pharmacists by providing a 'hands-on" approach to total quality patient care. Works closely with patients to deliver a full continuum of medication adherence support to include patients prescribed specialty medications to ensure the appropriate therapies are not interrupted or delayed by:

• Developing and maintaining strong relationships with members, co-workers, providers, facilities, and vendors
• Using his/her pharmacy technician and health plan expertise to review and manage escalated problems from clerical and clinical staff with drug or medical claims and clinical notes for prescription drugs, prior authorizations, and claims to ensure the appropriate drugs or therapy class of drugs are being prescribed for FDA-approved diagnoses and meet appropriate payment criteria
• Serving as the technical liaison on the Pharmacy Benefits Management, Care ContinuUM and Specialty Pharmacy teams, ensuring these vendors are held to the terms of their contracts’ service level agreements, pricing, and operational support to UHA and its members
• Independently using his/her judgement and discretion to craft pharmaceutical-related verbal and written communications to UHA members, providers, pharmacies, and hospitals based on quality interventions
• Making recommendations on UHA’s Drug Formulary in terms of which drugs to exclude and which drugs to include but technically influence by employing step therapy, quantity limits and/or prior authorizations
• Analyzing and implementing technical controls for when MDs may “buy and bill” for drugs that must otherwise be purchased at specialty pharmacies, (e.g., Rheumatology drugs that require sterile conditions and safety regulations be met which can only be performed in certified specialty pharmacy locations)

Essential Duties & Responsibilities:

• Screens and independently analyzes members’ medical or prescription claims, prior authorizations, quantity limits, and step therapies for accuracy, completeness and meets payment criteria
• Synthesizes and delivers recommendations to UHA leadership regarding coverage and challenges associated with various medications or therapy class drugs
• Performs complicated technical calculations to be sure the medications are billed properly, and dosing is appropriate for the conditions and diagnoses they are prescribed for
• Conducts pharmacy-related technical research if providers or pharmacies warrant investigation and claims review by the Program Integrity team (i.e., evidence collection, case preparation, analysis, and reporting potential outcomes)
• Independently uses pharmacy technician knowledge to calculate weight-based prescriptions based on Redbook’s listing of average wholesale prices (AWP), review product inserts (PI’s) and black-box warnings to prepare responses to members’, providers’, pharmacies’ complaints or escalated calls to the Director of Medical Informatics, Pharmaceuticals & Data
• Determines if Peer-to-Peer discussions are necessary
• Enforces pricing terms of the PBM drug contract
• Advises clinical staff on drug compliance and dispensing criteria
• Formulates a plan and acts on member and provider inquiries regarding drug coverage, prior authorizations and claims
• Creates testing scenarios to ensure proper drug and medical claims payments
• Develops training materials for other staff
• Independently uses relevant expertise to review, recommend and maintain Medical Payment policies annually to ensure policies are accurate and aligned with medical/pharmaceuticals industry standards
• Conducts Rx research for generic alternatives, overrides, and complaints while ensuring the PBM/MBM ‘Issues log’ is appropriately managed by the PBM
• Performs appropriate privacy measures for all forms of paper or electronic media to ensure no HIPAA breaches occur
• Per URAC accreditation standards, unless a licensed clinician performs these duties, this position prohibits any activity that requires interpretation of clinical information to customers, including the choosing of a set of criteria to use for handling a request for healthcare services or treatment

Required Education and Experience:

To perform this job successfully, an individual must be able to perform each essential duties satisfactorily with pharmacy and health plan knowledge/expertise. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• High School Diploma
• Three years demonstrated experience using technical learning and agility in a pharmacy- or health plan-related setting
• Three years of pharmacy, specialty pharmacy, or health plan experience required

Preferred and Advanced Qualifications:

• CPC or PMP certification preferred
• Bachelor’s degree from an accredited college or university

Physical Demands/Working Conditions:

The work environment characteristics described here are representative of those associate encounters while performing the essential functions of this job.

• Frequent sitting, reaching, bending
• Prolonged use of a computer terminal, keyboard/mouse
• Must be able to work independently and demonstrate responsibility in performing duties required of this position
• General understanding of medical terminology
• This position is a work from office

**Only Hawaii residents will be considered for this position**

Competitive compensation & excellent benefits offered

Visit our website at https://uhahealth.com/page/career-opportunities to apply and for details about vacant positions.

An Equal Opportunity Employer