The Pharmacist Utilization Management oversees the administration of the pharmacy department's utilization management program for both traditional pharmacy and infusion-related medications. This individual provides clinical support for other departments quality and health management efforts. This role assists in the development and evaluation of the plan formulary and benefit designs.
Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required), at our office in Brookfield or Menasha, or a combination of both in our hybrid workplace model.
Hours: 1.0 FTE, 40 hours per week, 7:30am - 5pm Monday through Friday
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Job Responsibilities:- Administrative/Operational Support
- Compliance Regulatory
- Professional Collaboration Support
- Quality Outcomes (including Medicare Stars, NCQA, HEDIS)
- Support and administer vendor oversight audits
- Participate in case management, disease management and poly-pharmacy for Network Health patients with extraordinary high drug costs
- Collaborate with formulary management team in development of utilization management criteria for Plan drug benefits including incorporating rebate optimization, branch logic, automation, and machine learning where appropriate.
- Assist with operational oversight of Medicare Part D Fraud, Waste & Abuse Program and other government programs
- Pharmacy benefit utilization and prior authorization real-time surveillance
- Assist in tracking the introduction of generic drugs/biosimilars to the marketplace and develops focused projects/programs to maximize the cost‑saving potential of these drugs and reduce costs in specific drug categories of the Plan formulary
- Perform retrospective reviews/audits on claims and prior authorizations for appropriateness
- Assist Sales, Member Experience, Providers, Brokers, and Community Partners with Pharmacy Benefit questions
- Assist in tracking the introduction of new drugs to the marketplace and advises the Pharmacy and Therapeutics (P&T) Committee on formulary decisions.
- Other duties and responsibilities as assigned.
- Bachelor of Science in Pharmacy required
- Current licensure without restriction by the State of Wisconsin Pharmacy Examining Board required
- A minimum of 3 years clinical experience required
- Residency/fellowship preferred
- Managed care experience desirable
- Driver's license required
Network Health is an Equal Opportunity Employer
Equal Opportunity Employer
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