Who we are:
Meridian is a family-owned, family-operated company of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.
We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in three different states (Michigan, Illinois, and Ohio).
Our employees work hard, play hard, and give back. Meridian employees enjoy: Happy hours, special events, company sports teams, potlucks, Bagel Fridays, weekly Executive Lunches, and volunteer opportunities.
A Day in the Life of a Utilization Management Pharmacist:
This position works under the direction of the Clinical Programs Team Lead and Manager of Clinical Operations and is responsible for review of drug utilization, formulary criteria, drug approval criteria, and policy & procedure (P&P) updates and requests related to management of drug utilization. The Utilization Management Pharmacist coordinates with internal and external stakeholders to develop, implement, monitor and oversee formulary enhancements that promote clinically sound and financially driven recommendations. The Utilization Management Pharmacist ensures all financial reports and formulary analyses are created and submitted at the request of any MeridianRx Client or pursuant to guidelines set forth by Contracts entered into by MeridianHealth or MeridianRx.
- Provide clinical and pharmacoeconomic support and recommendations to the Manager of Clinical Operations relating to formulary, criteria, and P&Ps that ensure safe, efficacious, and cost-effective prescribing and drug use
- Maintain drug pipeline for pharmacy benefits and medication related medical benefits (JCodes)
- Collaborate closely with other departments to review and analyze utilization data to provide recommendations supporting the use of efficacious, cost-effective therapy
- Work in conjunction with Clinical Programs team to support development and alignment of clinical programs for medical and pharmacy benefits with utilization management trends and analysis
- Provide clinical support for client and State requested reports, drug monograph review, clinical criteria development, formulary enhancement review, drug utilization review, etc. as needed.
- Maintain, facilitate access to, and distribute clinical formulary information, recommendations for formulary drug positioning, and revision of utilization management in collaboration with the Clinical Operations Leadership, Chief Medical Officer, and other key stakeholders
- Track, monitor, and analyze utilization reports to regularly assess implementation of clinical and policy decisions
- Coordinate information from drug manufacturers related to P&T review, quality improvement review, utilization management review, including manufacturer incentives and rebate programs
- Respond to day-to-day business issues with subject matter expertise
- Maintain awareness of trends, developments and governmental regulations in managed healthcare organizations and government programs
- Review and analyze prior authorization trends and utilization trends to provide comprehensive review and recommendation of drug approval criteria updates, formulary guideline updates, and P&P updates.
- Partner with the internal departments to provide clinical support for medication and therapeutic class related projects, creation of drug specific resources as needed.
- Perform other duties as assigned
- Bachelor’s degree in Business, Healthcare of a related field is preferred
- PharmD or graduate degree is required
- Residency and/or Board Certification is preferred
- At least two years of experience in managed health care or pharmacy programs is preferred
- Previous experience in Medicare and/or Medicaid programs is required
- Extensive experience and professional training likely to include industry certifications or advanced degrees are preferred
- Knowledge of Medicare Part D requirements and HPMS submission processes is preferred
- Expertise in clinical program components, formulary designs, and prescription drug benefit trends is required
- Demonstrated adaptability and flexibility to changes and response to new ideas and approaches is required
- Superior verbal and written communication skills
- Superior analytical and problem solving skills
- Superior computer skills
- Demonstrated willingness to work in a fast-paced, team-oriented environment, while maintaining a constant focus on quality-improvement and member satisfaction opportunities
- Ability to demonstrate patience, courtesy and professionalism with all internal and external stakeholders
- Ability to learn new skills and acquire knowledge in both the independent and group setting
- Ability to think critically, identify issues with current processes and propose solutions to identified issues
Equal Opportunity Employer