Job Description

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

The leveraged clinical pharmacist will report to the PBM Practice Director of Operations and be responsible for participating in all aspects of the Gainwell Technologies Pharmacy Benefit Management (PBM) business development, implementation, clinical services, and leveraged operations. This position will involve multiple facets of the pharmacy services including PA criteria development and coordination of Pharmacy and Therapeutic Committee (P&T) and DUR Board meetings, working closely with internal staff in the refinement of the medical pharmacy management solutions programs, working with the formulary management team on PDL development providing consultation on pharmacy issues to clinical operations representatives and facilitating the successful implementation of these programs for customer organizations.

Your role in our mission

Essential Job Functions

· Therapeutic Class Review (TCR) Development: Evaluate drug and drug class reviews based on sound evidence-based research and processes widely accepted by the medical profession. Create and update Gainwell TCRs based on information gathered, ensuring the content informs the recommendations for management of the preferred drug list (PDL) and clinical prior authorization (PA) criteria.

· Prior Authorization Criteria Development: Use appropriate methods that support the principles of high-quality evidence-based medicine to develop clinical PA criteria recommendations and documents to present to P&T and/or DUR Board.

· PDL Management: Provide a thorough review of the clinical and pricing data to assist the Gainwell clinical PDL team in preparation for multiple state P&T Committee or DUR Board meetings.

· Retro DUR Initiatives: Regularly review and monitor prescription claims data and prescribing practices identified as outliers by internal and/or external analysis of pharmacy claims data to develop relevant Retrospective DUR initiatives.

· Quality Improvement: Contribute to program improvements by using continuous quality improvement processes, by being proactive in identifying improvement opportunities and by contributing on-going consultation and collaboration with product leaders.

· Automated prior authorization: Assist various accounts in developing and maintaining question sets and rules for Intelligent PA (Auto PA during claims adjudication) and Electronic PA (EPA-prior authorization submitted electronically by prescriber through their EMR to the Gainwell system)

· Medical/Clinical: Uphold clinical integrity of pharmaceutical solutions by staying up to date on medication information, contributing to the identification of pharmacy program best practices, collaborating with Medical Directors,

Medical Dept, and Clinical Dept and provides pharmacy expertise within the organization.

· Contribute creative solutions to improve operational efficiency and effectiveness of the account pharmacy teams.

· Offer any assistance needed to the various accounts through implementations and maintenance and operations.

· Provide subject matter expertise for all pharmacy product development, sales pursuits, RFP responses, and DDIs.

· Engage with the development teams to provide business input and guidance on product enhancements and technical tools.

· Encourage and strengthen cohesiveness and team unity across the pharmacy business on all Gainwell accounts.

· Participate in corporate pharmacy team meetings.

What we're looking for

· Minimum of five (5) years of experience in pharmacy benefit management.

· Minimum of three (3) years of experience working with a Medicaid PBM account.

· Detailed knowledge of Medicaid at the state and federal level.

· PharmD required

· Working knowledge of HIPAA regulations and requirements.

What you should expect in this role

100% remote with 10% travel expected. 

The pay range for this position is $113,700.00 - $162,400.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies  is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. 

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