Aetna Clinical Pharmacy Manager in Phoenix, Arizona
Req ID: 52301BR
Please note: This is an in office position in Phoenix, AZ.
Manager of the Medicare-Medicaid Coverage Determination Clinical Pharmacist Review Team. Will be responsible for managing staff and maintaining an end-to-end Coverage Determination process that is compliant with all CMS and NCQA requirements.
Provide direct supervision and support to the Medicare-Medicaid Coverage Determination Clinical Pharmacist Review Team
Complete monthly 1:1 meetings with each assigned team member throughout 2018.
Provide monthly progress in a documentation form to direct reports at each meeting.
Meet all health plan contractual and CMS requirements for completing prior authorization reviews within the established turnaround time (TAT) at 100% throughout 2018.
Contribute by completing 20 PA activities per month and coverage support during peak volume and PTO / vacancies. Quality monitoring of the clinical pharmacy team review process throughout 2018; including: Review daily and monthly quality monitoring results. Support and maintain denial language templates in compliance with state/contractual requirements, NCQA standards and PA Guidelines throughout 2018.
Provide support to the Pharmacy Residency program as necessary throughout 2018.
Complete assigned NCQA quality audits as assigned throughout 2018 and provide support to Director, Service Operations. Complete a review of the quality audit results and tool to identify opportunities for additional audit measures related to the use and application of the PA Guidelines and NCQA and CMS requirements Collaborate with the PA Guideline team in the development of Inter-rater Reliability quizzes to evaluate clinical application of the PA Guidelines for o Clinical Pharmacist (Quarterly) Medical Directors and Technician Staff (Annually) Identify and evaluate coaching opportunities for staff on appropriate application and use of the PA Guideline/Questions and review with staff member UAT and quality check of CAS criteria and PA guideline New Plan/Migration Training Support
Collaborate with health plan and pharmacy director on training materials to provide plan overview of program, benefits, formulary and PA Guidelines to the specific state requirements for the Pharmacy Call Center Team (Pharmacy Technicians / Clinical Pharmacists)
Training and post implementation/migration support to Medical Directors, Case Management, and Member Services on PA processes the ops team, Medical Directors and new pharmacy directors on PA process Develop and maintain new hire training materials for clinical pharmacists and pharmacy directors on PA policies and procedures Demonstrates the Aetna Way values and behaviors in achieving business results.
In-depth knowledge and experience in managed care, managed pharmacy and competitive environment is required
3+ years clinical administrative experience in pharmacy related industry, or equivalent is preferred
Previous supervisory or leadership experience is preferred
The minimum level of education desired for candidates in this position is a Doctor of Pharmacy.
LICENSES AND CERTIFICATIONS
Pharmacy/Licensed Pharmacist is required
Functional - Clinical / Medical/Precertification/1+ Years
Functional - Management/Management - Operations/1+ Years
Leadership/Collaborating for Results/FOUNDATION
Benefits Management/Interacting with Medical Professionals/ADVANCED
ADDITIONAL JOB INFORMATION
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.
We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.
Together we will empower people to live healthier lives.
Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Aetna takes our candidates's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.
Job Function: Health Care