Reporting to the Director of Pharmacy, the San Francisco Health Plan (SFHP) Clinical Pharmacist, Medicare will work closely with the Pharmacy Benefit Manager (PBM), healthcare providers, beneficiaries, and internal team members to ensure that SFHP's Part D plans are managed, cost-effective, and compliant with regulatory requirements.
Salary: $130,000 to $180,000 annual
WHAT YOU WILL DO:
The Clinical Pharmacist, Medicare performs the following responsibilities in collaboration with the pharmacy team and other internal and external partners. The responsibilities listed below may be delegated to one staff Clinical Pharmacist or shared responsibility of all staff Clinical Pharmacists.
Clinical Support, Stars and Medication Therapy Management (MTM):
Clinical Consultation: Provide clinical support to the managed care team, physicians, and other healthcare providers to increase medication therapy for beneficiaries. This includes helping providers choose cost-effective, evidence-based treatments.
Medication Therapy Management (MTM): Provide oversight of delegated MTM services to improve the quality of care for Medicare beneficiaries. This includes reviewing medications for drug interactions, side effects, duplication of therapy, and opportunities for improving adherence. Reach out to beneficiaries to conduct these reviews.
Adherence Monitoring: Identify patients at risk of non-adherence to their medications, provide counseling to improve adherence, and implement strategies to reduce gaps in care.
Be available to Health Services staff for ad hoc information queries related to the medications being taken by members for whom staff is providing either direct care coordination or utilization review
Compliance and Regulatory:
CMS Regulations Compliance: Ensure that the organization's Medicare Part D plan complies with the Centers for Medicare & Medicaid Services (CMS) regulations and guidelines. Ensure the formulary and drug utilization practices meet all CMS requirements.
Audit and Monitoring Support: Assist with internal and external audits related to Part D compliance. Provide documentation, data analysis, and explanations of clinical decisions to ensure the organization meets regulatory standards.
Reporting: Prepare reports for CMS and internal stakeholders about drug coverage, medication utilization, and any clinical interventions made to improve patient care.
Formulary Management:
Developing and Maintaining Formularies: Oversight of PBM delegated formulary, which is the list of drugs covered under the Medicare Part D plan. Review new and existing drugs, ensuring appropriate inclusion/exclusion based on clinical evidence, efficacy, cost-effectiveness, and member needs.
Drug Utilization Review (DUR): Conduct reviews of drug utilization patterns to ensure appropriate prescribing, identifying potential medication-related issues, and recommending cost-effective alternatives. Ensure formulary compliance and the proper use of medications.
Prior Authorization Management: Oversee the PBM delegated prior authorization processes to ensure that prescribed medications meet clinical and formulary guidelines. Review requests, communicating with prescribing physicians and make recommendations regarding whether the medication should be approved or denied.
Provide support for Appeals and Grievances process including clinical review of appeals, documentation via the case management tool, and case presentation and follow-up via the Utilization Management Committee (UMC). Provide PBM PA team oversight and communication/retrain, and identification and operationalization of PA criteria and process improvement opportunities
Part D Education:
Member Education: Educate beneficiaries about their Medicare Part D benefits, formularies, and medication coverage options. Help members understand their prescription drug costs, the formulary, and available support programs.
Provider Education: Provide education and resources to healthcare providers about formulary changes, medication guidelines, and the appropriate use of medications within the Medicare Part D plan.
Internal Team Education: Support education and resources to other teams to enable understanding of Part D plan structure, benefits and programs.
Data Analysis and Outcomes:
Drug Utilization Analysis: Analyze prescription drug claims data to identify patterns of drug use, potential therapeutic issues, and opportunities for improving care. Identify high-risk patients, high-cost drug categories, and trends in medication usage.
Outcome Measurement: Evaluate the outcomes of interventions, such as formulary changes or adherence programs, to assess their effectiveness in improving clinical outcomes and reducing overall costs.
Other Areas of responsibilities:
Collaborate with Health Services staff to address population health priorities and align efforts via QI, DUR and other programs
Bring issues to the attention of the Pharmacy Director with recommendations for solutions
Support the University of California San Francisco pharmacy school Advanced Pharmaceutical Practice experience rotation via student precepting (primary or supportive role) and rotation development and maintenance
WHAT YOU WILL BRING:
Registered Pharmacist (Doctor of Pharmacy Preferred) with a valid and unrestricted California State license.
Experience with one or more of the following, 3 years preferred:
Knowledge of Medicare Part D regulations, formulary management, and CMS guidelines.
Familiarity with CMS regulations related to Medicare Part D and experience in a managed care environment is preferred.
Medication Therapy Management program development or delivery
Drug Utilization Review analysis, development, or delivery
Quality Improvement program development or delivery
Formulary management development or delivery
Experience in an HMO or experience in managed care setting, preferred
Knowledge of and experience with state and federal insurance programs, preferred.
Knowledge of the San Francisco health community, including public and private entities and their role in the provision of health care to San Francisco residents.
Familiarity with relevant local, state, and federal regulations.
Familiarity with health care, managed care terminology, or Medi-Cal preferred.
Extensive knowledge of pharmacy workflow from prescription to claims submission and authorization request processing.
WHAT WE OFFER:
Health Benefits
Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
Retirement – Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
Time off – 23 days of Paid Time Off (PTO) and 13 paid holidays.
Professional development: Opportunities for tuition reimbursement, professional license/membership.
ABOUT SFHP:
Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.
San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
San Francisco Health Plan is an E-Verify participating employer.
Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.
