Your career starts now. We’re looking for the next generation of health care leaders.
At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.
- Perform medication therapy reviews to identify medication related problems.
- Target members for interactive consultations based on a variety of risk stratification scenarios.
- Performs interactive consultations and makes recommendations/interventions for members and providers, appropriately documents all pharmacotherapy interventions, responds to questions and provides clarification for requests generated in regards to MTM/DTM programs.
- Present all relevant DTM/MTM program materials to P&T committees as well as any other internal or external review required by assigned plan.
- Handle calls and correspondence from providers; responds to inquiries and complaints. Document calls in inquiry tracking system. Using established protocols ensures resolutions provided are presented in a clear and accurate manner. Receive escalated calls that cannot be clinically resolved by 1st level intervention. Research, resolve and respond to provider clinical inquiries in regards to DTM.
- Support Fraud and Abuse program system oversight. Communicate to Compliance any suspected fraud discovered. Recommend course of action for providers where patterns appear outside of guidelines and generally accepted pharmacy standards.
- Analyze reports for members identified as opioid over utilizers. Conduct consultations with prescribers and submit point-of-sale edits to claims processor for members over utilizing opioids.
- Serve as second-line contact for all ACFC pharmacy related issues. Ensures internal changes that may affect network services are reflected in the claims processing system.
- Plan and implement member in-service education. May conduct one on one or group in-services for members, providers, and associated office personnel.
- Represent PerformRx in contacts with providers, members, hospital personnel, etc. Demonstrate an understanding of PerformRx’s protocols for dealing with external organizations, groups, vendors, and individuals.
- Keep abreast of industry trends and regulatory changes in the pharmacy industry and evaluates their effect on pharmacy contracts and services. Makes recommendations on program improvements, based on findings and utilization.
- Assist in implementation of new DTM programs. Serve as a lead for following up and completing implementation tasks for new lines of business.
- Coordinate with internal departments and external clients on DTM projects.
- Serve as a resource to resolve issues identified by DTM Technicians and DTM Analyst.
- Provide on-going pharmacy policy and procedure review as well as desktop procedure review and updates as appropriate.
- Serve as central point of information distribution to members of Pharmacy staff.
- Review appropriate clinical material (primary literature, clinical guidelines, etc.) and monitor new drugs released to market to update clinical recommendations for gaps in care algorithms for internal and external clients.
- Assist in coordinating department staff projects including coordinating patient care with internal and external practitioners, pharmacist disease specialties, pharmacy journal club, and new drug information.
- Maintain a balance of productivity, quality, and timeliness of job accountabilities. Participate in department self-audit procedures for on-going evaluation of services.
- Assist in coordination of pharmacy student and pharmacy intern projects.
- Assist in training new staff.
- Perform other job related duties and projects as assigned.
- Assist Prior Authorization Department when additional resources are needed.
- Has attended MTM/DTM certificate training.
- Comply with URAC/CMS standards and regulation for DTMP.
- Current pharmacy license, Commonwealth of Pennsylvania preferred. Pharm D. preferred.
- Previous 1+ years’ experience in a managed care environment required. MTM/DTM certificate training preferred.