Pharmacy Services Specialist; Clinical Programs - Stars

Pharmacy Services Specialist (Clinical Programs ‑ Stars) – Cal Optima

Join Us in this Amazing Opportunity

We are a mission driven community‑based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

We are hoping you will join us as a Pharmacy Services Specialist (Clinical Programs ‑ Stars) and help shape the future of healthcare where you ll be an integral part of our Pharmacy Management team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders.

This position has been approved to be Full Telework
.

• If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

You will utilize specialized pharmacy knowledge and expertise to assist participating pharmacies, members, providers, Cal Optima Health departments, health networks and other entities in assuring the efficient, timely and effective provision of pharmaceutical products and services to Cal Optima Health members. You will interact with other department staff throughout the organization, as well as external contacts daily. You will be responsible for ongoing public contacts including, but are not limited to, members, individual pharmacies, member advocates, family members, health networks, Public Guardian s Office, Regional Center and other agencies.

Together, we are building a stronger, more equitable health system.

• 85% ‑ Program Support
  • Participates in a mission‑driven culture of high‑quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Conducts outbound calls to members, pharmacies, and providers in an effort to improve Star measure performance for medication adherence and other Star programs as needed.
  • Using a pharmacy computer program, retrieves drug‑specific technical data and information necessary for the completion of departmental and interdepartmental pharmacy‑related functions and operations.
  • Assists with resolution of provider and member pharmacy issues requiring specialized technical and professional knowledge and expertise, including pharmacy authorizations.
  • Supports the department with claims disputes between providing pharmacies, the pharmacy claims administrator, Cal Optima Health Claims Department and other entities as necessary.
  • Interprets and articulates Pharmacy Management program policies and procedures to pharmacy providers, other providers, other Cal Optima Health staff, external agencies and others as required.
  • Assists in the processing of pharmaceutical prior authorization and appeals requests as per the Cal Optima Health Prior Authorization Guidelines as needed.
  • Establishes and maintains key contacts both internally and externally to assure appropriate coordination and provision of pharmacy services to Cal Optima Health Members.
  • Accepts referrals from Member Services and work in conjunction with employees from this department to resolve all pharmacy‑related member complaints, including those related to the pharmacy authorization process.
  • Assists pharmacies and health plans in resolving member‑specific pharmacy services access issues, removing barriers to access to pharmaceutical services.
  • Identifies pharmacy‑related resources and recommend new procedures, processes or activities that help assure the efficient provision of pharmacy services to members.
• 10% ‑ Administrative Support
  • Assists the team in carrying out department responsibilities and collaborates with others to support short‑ and long‑term goals/priorities for the department.
  • Maintains documentation of the Stars adherence program and other Stars program outreach according to the internal guidelines.
• 5% ‑ Completes other projects and…