As one of the nation’s largest not-for-profit Medicare Advantage plans, serving more than 200,000 members in California, SCAN Health Plan has been a mission-driven organization dedicated to keeping seniors healthy and independent for over 40 years. SCAN employees are passionate about what they do, and understand that success is based on achieving the mission. Employees are afforded with the training and tools necessary to do their jobs and are rewarded for their efforts and recognized as experts in their fields. To learn more, visit scanhealthplan.comor follow us on social media:LinkedIn; Facebook; andTwitter.
Reporting into the Manager, Pharmacy Experience & Access this position will play an instrumental role in ensuring compliance and clinical appropriateness of Part D coverage determinations, appeals and grievances, and Part C organizational determinations for a senior-focused Medicare Advantage Plan. The Clinical Pharmacist will work alongside the Director to execute and ensure CMS compliant operations and strong star rating performance for these areas. In addition, the Clinical Pharmacist will support Interdisciplinary Care Team work, and complete medication-related clinical reviews to support the care management teams at SCAN. The Clinical Pharmacist will participate in other managed care responsibilities as assigned.
Serve as a subject matter expert of Part D coverage determinations, redeterminations, and applicable Part C organizational determinations
Utilize Medicare Part D knowledge and expertise to ensure compliance and clinical appropriateness with coverage determinations, appeals, and grievances.
Produce and maintain Prior Authorization criteria and Step Therapy criteria in accordance with CMS requirements on monthly and annual basis.
Develop and maintain formulary exception criteria.
With direction from the Manager, develop, coordinate and implement an effective on-going strategy to achieve strong star ratings and audit readiness for assigned functions.
Serve as the clinical appropriateness subject matter expert during regulatory audits.
Ensure rigorous daily monitoring of operations for compliance performance.
Contribute in quality improvement and process enhancement projects internally and with contracted PBM.
Foster strong relations with internal departments and contracted PBM.
Serve as pharmacy expert on Interdisciplinary Care Team, other committees, and workgroups as required.
Support the care management teams by reviewing records of patients to determine the appropriateness of medication therapy, consulting on dosages, and collaborating with healthcare professionals to ensure optimal patient care
Serve a clinical bridge to the Formulary & Benefits team on effectiveness and considerations for additional formulary utilization management strategies.
Maintain current knowledge of relevant Medicare Part D regulations by participating in CMS calls and reading released guidance and implementing changes/updates to maintain compliance.
Maintain professional and technical knowledge by attending educational workshops.
Pharm. D. degree required.
Current Pharmacist Licensure in California required.
Completion of residency/fellowship in Managed Care preferred.
Prior experience working with CMS Part D regulations required.
Strong clinical skills required.
Ability to work cross-functionally across the organization.
Excellent written/oral communication skills
Self-starter who can work independently
Ability to multi-task in a fast environment
Ability to research, analyze, and problem solve
Strong critical thinking skills
What's in it for you?
A competitive compensation and benefits program
An annual employee bonus program
Generous paid-time-off (PTO)
Ten paid holidays per year
Excellent 403(b) Saving Plan, providing up to 4% match and vesting after three years
A work-life balance and much more!
We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!
At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.
SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employee will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
Internal Number: CLINI03637
About SCAN Health Plan
As one of the nation’s largest not-for-profit Medicare Advantage plans, serving more than 200,000 members in California, SCAN Health Plan has been a mission-driven organization dedicated to keeping seniors healthy and independent for over 40 years. SCAN employees are passionate about what they do, and understand that success is based on achieving the mission. Employees are afforded with the training and tools necessary to do their jobs and are rewarded for their efforts and recognized as experts in their fields. To learn more, visit scanhealthplan.com or follow us on social media: LinkedIn; Facebook; and Twitter.