Job details

Clinical Pharmacist I

Join our team of dedicated professionals who are committed to ensuring our clients can provide affordable health benefit solutions for their employees.

Pinnacle Claims Management is a 3^rd party administrator that provides health benefits administration and related services to companies that self-fund their insurance. We are also a contracted partner with CCSB.

Pinnacle is independently owned and has been serving clients for 20+ years. We are also part of the Western Growers Family of Companies.

Compensation: $109,920 - $137,800 with a rich benefits package that includes profit-sharing.

Job Description Summary

This position reports directly to the Vice President, Health Management and Clinical Services and is responsible for assisting with the research, development, and maintenance of clinical pharmacy programs, including clinical initiatives that impact drug utilization, clinical education and staff development, management of appropriate drug utilization, drug spend analysis, and quality improvement activities related to pharmaceuticals. This position will assist in the oversight of daily operations of the Pharmacy and Formulary department. Participate in care management as a member of the interdisciplinary care team, and will perform medication assessments for members. Assist with conducting oversight audits and focus on continuous monitoring activities.

Qualifications

Minimum one (1) to three (3) years of retail pharmacy experience, and one (1) year of managed care pharmacy internship, residency or similar experience in a Pharmacy Benefit Management (PBM) setting. Doctorate in Pharmacy and registered pharmacist license in California or equivalent, preferred.
Valid CA Registered Pharmacist License
Prior experience in pharmacy auditing and/or PBM preferred;
Ability to understand complex situations and make independent decisions;
Highly proficient in end-user computer skills with Microsoft Office applications.
Excellent written and verbal communication skills;
Proven ability to multi-task multiple projects and demands at one time.
Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds. (This language is needed as part of the job requirements only if the position is 100% remote or hybrid. Please remove language if this position does not meet this criterion.)
Home router with wired Ethernet (wireless connections and hotspots are not permitted). (This language is needed as part of the job requirements only if the position is 100% remote or hybrid. Please remove language if this position does not meet this criterion.)
A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.) (This language is needed as part of the job requirements only if the position is 100% remote or hybrid. Please remove language if this position does not meet this criterion.)
A functioning smoke detector, fire extinguisher, and first aid kit on site. (This language is needed as part of the job requirements only if the position is 100% remote or hybrid. Please remove language if this position does not meet this criterion.)

Duties And Responsibilities

Clinical Support

Work with internal partners to develop, and maintain, a pharmacy claims audit program to support internal pharmacy and client contracts.
Assist in developing criteria for medication analysis and claims monitoring in alignment with Clinical Operations initiatives and regulatory reporting requirements.
Collaborate on the development of clinical edits for claims and drug utilization enhancements.
Help evaluate quality controls and suggest performance improvement opportunities in pharmacy practices.
Support the development and maintenance of a pharmacy claims audit program to meet internal and client needs.
Assist in expansion, conversion and management of Cedar clinics sites and health fairs.
Work with our educational partners in establishing meaningful and impactful programs for the benefit of members and education of new pharmacy students and interns.

Operations & Administration

Support analytics and outcomes initiatives related to clinical programs.
Audit claims for accuracy in pricing, appropriateness or for potential fraud waste and abuse.
Educate and precept pharmacy students and interns during experiential rotations.
Contribute to operational improvements and initiatives identified by leadership.
Assist with analytics and outcomes related to clinical programs.
Review and make determinations for prior authorization requests based on member benefits and coverage.
Help oversee drug utilization review and medication therapy management programs to ensure compliance with plan and PBM requirements.
Support systematic reviews of prescription claims to meet strategic initiatives.
Provide clinical support and drug information expertise to internal teams.
Stay updated on drug information and disease management as it relates to utilization reviews.

Other

Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
Maintain a valid CA Pharmacist License.
Attend client or off-site meetings or conferences as requested by the Supervisor.
Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here represent those that an employee must meet to successfully perform this job’s essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.