Clinical Pharmacist, Specialty Drug Cost Containment

This position helps support the health plan’s comprehensive medication management program through proactive identification of high-impact members who are utilizing high-cost specialty medications.

The role plays a critical part in executing pharmacy-driven cost reduction strategies, including support of stop-loss initiatives, while ensuring clinically appropriate and member-centered care in collaboration with providers, members, pharmacies, and internal teams.

Under the direction of Pharmacy Care Coordination leadership, this role is responsible for evaluating cost effective treatment regimes, with a focus on optimizing specialty medication use, improving member outcomes, and reducing total cost of care.

Essential Accountabilities

Level I

Utilizes prescription and medical claim data to generate clinical recommendations and conduct comprehensive medication reviews for members, with a focus on high-cost specialty therapies and complex drug regimens.

Collaborate with members and providers to recommend clinically appropriate therapy alternatives, dose optimization, or deprescribing opportunities

• Perform detailed clinical and financial review of high-cost and stop-loss eligible pharmacy claims.
• Recommend alternative treatment pathways, contracting considerations, or program enrollments to reduce stop-loss exposure.
• Support initiatives to improve specialty medication adherence and appropriate utilization.

Support execution of workflows, including both manual and technology-enabled workflows through platform development

Evaluates medication related problems such as adverse events, therapeutic duplication, adherence to therapy, polypharmacy, and untreated disease or conditions.

Analyzes, documents, and reports member outreach and intervention performance results relative to reporting requirements for strategic initiatives related to high-cost pharmacy claim reduction efforts.

• Utilizes formulary information and member specific benefits to guide appropriate medication recommendations.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

Collaborates with internal groups to create and implement program strategies that address highly complex members and other members eligible for pharmacy outreach that demonstrate cost avoidance and/or cost savings while addressing the needs of these members.

Actively monitors the drug pipeline and provides education to members and case management teams as it relates to future trends and opportunities.

Develops strategies and reporting for pharmacy case management opportunities and referral opportunities for case management teams of all specialty types.

Maintains caseload of highly complex members enrolled in pharmacy outreach strategies and tracks outreach impact, including outcome trends, spend, and provider/member satisfaction.

Works closely with clinical strategy and medical management teams and external resources to enhance current strategies and processes for both commercial and government programs.

Develops and maintains automated reporting and organization of pharmacy case management caseloads, value stories, and process improvement.

• Prioritize and manage outreach based on predictive insights, savings potential, member risk and ROI potential.
• Drive program scalability using thorough evaluation of line of business differentiators that may impact outcomes and cost reduction strategies.
• Acts as mentor to new staff as needed, to increase their knowledge and skillset.

Minimum Qualifications

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels

Current New York State Pharmacist License

Pharm.D. or Bachelor of Science in Pharmacy, plus at least two years of experience in an organized healthcare setting, or completion of a PGY-1 residency.

Managed care experience is strongly preferred, especially experience with direct physician interaction, clinical practice, or direct patient interaction

Excellent interpersonal, consultative, and problem-solving skills.

Excellent verbal and written communication skills with experience communicating with members, and other health care professionals.

Ability to effectively manage multiple patient care plans and/or claims files in a fast-paced environment, while maintaining attention to details and accuracy.

Knowledge and skill to conduct a thorough drug regimen review. Strong clinical knowledge kept current through continuing education and professional affiliations.

Strong computer skills. Proficient knowledge of Microsoft Word, Excel, Outlook and PowerPoint. Ability to learn new systems.

Level II (in addition to Level I Qualifications)

Minimum of three years of experience in an organized health care setting with strong clinical pharmacy knowledge including participation in patient management initiatives.

Extensive knowledge of innovative managed care pharmacy programs and a proven clinical track record of developing cost-effective, high-quality programs.

Extensive command of specialty practice, including diseases, published literature and medication therapies for specific patient populations.

Innovative thinking and effective communication on clinical decision making and pharmacy case management strategies within the division and outside of the division.

Ability to track and identify drug trends through claims data and member experiences to report and collaborate initiative ideas that are not otherwise captured by another pharmacy area.

Experience working with highly complex members with physical and behavioral health needs.

Physical Requirements

Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.

• Typical office environment including fluorescent lighting.
• Ability to work in a home office for continuous periods of time for business continuity.
• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
• Manual dexterity including fine finger motion required.
• Repetitive motion required.
• The ability to hear, understand and speak clearly while using a phone, with or without a headset.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s)

E8: $98,297 - $176,935

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position.

Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package.

Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.