Health Plans

Coverage Determinations, Appeals, and Grievances

General Responsibilities:
In the role of Pharmacy Coverage Determinations, Appeals and Grievances, the responsibilities entail overseeing prior authorizations and overrides. The role also works with reviewing pharmacy cases of appeals and grievances

Day-to-day schedule:

  • Attend scheduled meetings
  • External meetings
  • Operational tasks
  • Team management
  • Project oversight

Interactions:

  • PBMs
  • Internal team – pharmacist and technicians

Qualifications:

  • PharmD
    • Residency: Required
  • Skills:
    • Microsoft Excel
    • Microsoft Outlook
    • Communication and teamwork
    • Time management
    • Independent task completion
  • Experience:
    • Management experience
    • Experience in managed care is not required but highly recommended

Clinical Pharmacy Services

General responsibilities:

High level of oversight and strategy over health outcomes.

Responsibilities include:

  • Oversight of quality of care of all services paid for by the plan
  • Managing prior authorizations/utilization management
  • Creating clinical programs and taking into consideration cost effectiveness
  • Quality accreditation and facility site review
  • Designing formularies and benefits
  • Patient safety and health education

Day-to-day schedule:

  • 95% is project-based. Meetings with different teams are set up to discuss details about different projects, what needs to be prepared, what needs to improve on, and operational efficiency.

Interactions:

Interactions consists of pharmacists, pharmacy technicians, health educators, quality improvement nurses, data experts, project managers, and other directors (utilization, long time support, etc.)

  • Interactions outside include: IT department, compliance, finance, claims, provider networks, etc.
  • Meetings may also include stakeholders, local doctors, local associations, and vendors (health education, cultural linguistic, PBMs, chain pharmacies, home infusions, etc.)
  • No direct patient interaction, however the team does for the clinical programs and prior authorizations.

Qualifications: PharmD

  • Residency: A residency is beneficial.
  • Skills:
    • Be able to both focus on details while seeing the big picture/outcome. Being capable of both, would make a good director.
  • Experience:
    • Jobs related to managed care (e.g. specialty pharmacy and home infusion will be helpful for managing drugs)
    • Networking with local organizations

Health Plans

A health plan provides, or pays the cost of, medical care. The role of a managed care pharmacist in a health plan is to evaluate and enhance the quality of patient care in a cost effective manner.

Pharmacy Benefit Manager (PBM)

Clinical Intervention Services

General responsibilities:

Main responsibilities include making sure material transfer to the P&T committee for FDA approval, using data to evaluate utilization of new drugs, and proposing physician paper to explain how to use the new drug with little present data.

Day-to-day schedule:

  • Address any compliance issues and grievances
  • Varies depending on active small or large projects

Interactions:

  • Data analytics to determine prior authoriazations
  • Centers for Medicare and Medicaid Services (CMS) regarding Medicare inquiries
  • Residents to help develop projects

Qualifications:

  • PharmD
    • Residency: Recommended to develop stronger clinical skills
  • Skills:
    • Clinical skills
    • Literature interpretation
    • Comprehensive thinking
    • Communication skills (written and oral)
    • Time Management
  • Experiences:
    • Clinical experience in acute care
    • Ambulatory care
    • Inpatient hospital setting

Client Management - Clinical Account Executive

General Responsibilities:

Main role is to work with employer groups and provide pharmacy benefits. Client data is analyzed and recommendations are made based on drug consumption, budget, and medication treatment alternatives.

Day-to-day or week-to-week schedule:

  • Independent work schedule
  • Answering employer emails & questions
  • Data entry into excel sheets and presentations

Interactions:

  • Employer groups
  • International team working with various employer groups

Qualifications:

  • PharmD
    • Residency: Managed Care Residency is highly recommended
  • Skills:
    • Strong written and oral communication skills
    • Comprehensive and critical thinking
    • Organization/Time management
  • Experience:
    • Prior managed care experience or residency

Industry Relations

General Responsibilities:

The role is diverse, but the main goal is to negotiate with brand pharmacy manufacturers for discounts and rebates, as well as look for opportunities to work with manufacturing partners.

Day-to-day or week-to-week schedule:

  • Communicate with pharmaceutical manufacturers
  • Discuss strategy with internal stakeholders, formulary team, and clinical/drug information team

Interactions:

  • Internal Teams: drug information, formulary, clinical
  • Pharmaceutical representatives
  • Stakeholders

Qualifications:

  • PharmD
    • Residency or Fellowship: Not required but fellowship or managed care residency recommended
  • Skills:
    • Interpersonal skills
    • Clinical skills
    • Interest/understanding of managed care
  • Experience:
    • Having clinical skills is extremely valuable
    • Managed care residency or fellowship
    • Experience in pharmacoeconomics

Pharmacy Benefit Manager (PBM)

Management of pharmaceutical benefits for managed care organizations, other medical providers or employers.  PBMs contract with clients interested in optimizing the clinical and economic performance of their pharmacy benefit.

Medical Groups

Clinical Pharmacist

General Responsibilities:

The role of a clinical pharmacist is to help out-of-state business raise their CMS Star ratings up by utilize MTM-skills to help optimize patient therapies to improve outcomes by resolving medication issues, cost savings/cost management, and providing educations for healthcare providers.

Day-to-day or week-to-week schedule:

  • Perform MTM calls during the morning or afternoon hours
  • Perform project-based tasks such as creating educational material for patients and providers

Interactions:

  • Patients
  • Internal teams

Qualifications:

  • PharmD
    • Residency or Fellowship: It’s not required but recommended
  • Skills:
    • Excellent written and oral communication
  • Experience:
    • Clinical care experience

Medical Group

Managed care pharmacist play an integral role within medical groups by optimizing patient outcomes while implementing cost saving strategies.

Consultants

Consultant

General Responsibilities:

The role as consultant entails providing information for new businesses, marketing teams, general marketing (e.g. social marketing, magazine), and data analytic program. The information can vary from but not only including PBM audits, financial analysis in public and private health plans, oversight of drug utilization, compliance audits, development of new products, patient care reviews, last appeal for meeting benefit requirements, and staff and clinical reporting.

Day-to-day or week-to-week schedule:

  • Performing analytics and critiques
  • Interacting with private and public health programs, insurance, clients, and employees
  • Modifying to improve clinically and financially
  • Researching data

Interactions:

  • Private and public health programs
  • Insurance companies
  • Clients and employees

Qualifications:

  • PharmD
    • Residency or Fellowship: Not required but recommended
  • Skills:
    • Understand mathematical probability
    • Problem solving
    • Strategic views of health plan and general payer problems
    • Good communication with different levels of clients
    • Ability to work with different types of people
    • Marketing
  • Experience:
    • Exposure to various managed care roles

Consultant

 

 

Academic Pharmacists

Academia - Pharmacoeconomics

General Responsibilities:

The pharmacy academia position with a background in Health Economics and Policy can involve teaching, precepting pharmacy students on Pharmacoeconomics, and Health Outcomes Research. There are also options to pursue collaborative research projects, teaching scholarships, or consulting for pharmaceutical companies on health economic-related topics.

Day-to-day or week-to-week schedule:

  • Flexible in academia
  • Majority of the time is spent in research

Interactions:

  • Faculty members
  • Pharmacy students
  • Pharmaceutical companies

Qualifications:

  • PharmD or PhD: Either is acceptable
    • Residency or Fellowship: Not required
  • Skills
    • Research skills
    • Quantitative skills
  • Experience
    • Internships to gain real-world experience
    • Networking

Academia

Engagement in both clinical and/or clinical research in the lab, classroom, or institution. Area of focus and specialty can vary from one to the other.

Pharmaceutical Manufacturers

Medical Affairs

Commercial

Legal

Medical Value and Access Communications

General Responsibilities:

Within pharmaceutical industry, there is an internal function and external function, the latter which involves reaching out in the community to healthcare professionals to ensure valuable information about disease states and products are delivered. Sr. Manager of Medical Value and Access Communications prepares medical liaisons and outcomes/pharmacoeconomic specialists by putting together data and information in a useable and digestible form for when the specialists are out in the field.

 

Day-to-day or week-to-week schedule:

  • Work with medical directors and observational research groups to put together data to present to medical liaisons
  • Review substantial data for the providers to ensure quality of care is given from the providers to the patients
  • Attend meetings (in a given week, about 60% of time is spent on core work, and about 40% on meetings, answering emails, and liaising internally)

Interactions:

  • Medical directors
  • Research groups
  • Outcomes/pharmacoeconomic specialists

Qualifications:

  • PharmD
    • Residency or Fellowship: Optional, but helpful
  • Skills:
    • Interpersonal skills
    • Presentation skills
    • Communication skills
  • Experience:
    • A variety of backgrounds and degrees in managed care
    • Clinical experience is valued, even in industry

Medical Communications

General Responsibilities:

Medical Communications are responsible for communicating externally to patients, providers, and payers of data pertaining to studies or disease states. The data generated from clinical studies can be developed into content for a product that is presented at conferences to show and educate. Medical Communications acts as a resource to answer any questions about products that patients or healthcare providers may have.

Day-to-day or week-to-week schedule:

  • Project based work from day to day (autonomy)

Interactions:

  • Majority of interactions are internally with colleagues
  • Occasionally reach out to physicians and patients
  • Working with both commercial and brand teams
  • Conferences with providers
  • Provider feedback

Qualifications:

  • PharmD or PhD
    • Fellowship: Recommended
  • Skills:
    • Written and oral communication skills
    • Presentation skills
    • Time management
    • Ability to work independently
  • Experience:
    • Exposure through APPEs
    • Internship programs

Medical Writing

General Responsibilities:

This position as in medical writing involves working in Phase 1 or 3 of clinical trials, designing clinical protocols on how to conduct clinical trial, writing up lab manuals, publications, abstracts, and manuscripts, and working with regulatory organizations. Medical Writers must also understand how to work with fast track designation for certain products and know when to update adverse reactions report to Medwatch.

Day-to-day or week-to-week schedule:

  • Highly flexible
  • Work from home remotely
  • Long term projects (3 months)
  • Teleconferences

Interactions:

  • Customers/Clients
  • Investigators
  • Regulatory organizations
  • Key Opinion Leader (KOL) for study design

Qualifications:

  • PharmD: Optional
    • Residency or Fellowship: Recommended
  • Skills:
    • Clinical research skills
    • Evidence-based practice
  • Experience:
    • Clinical research
    • Networking
    • Any pharmaceutical industry experience

Health Outcomes and Economic Research

General Responsibilities:

Responsibilities involve an understanding of clinical information from 20 different products & disease states at a given time. Utilizing clinical data and pharmacoeconmic research to improve quality of care through risk stratification and proper drug selection.

Day-to-day or week-to-week schedule:

  • Remotely work from home
  • Scheduled meetings with various providers

Interactions:

  • Variety of stakeholders
  • Primary care providers
  • Medical Plans
  • Health Groups
  • Clinical pharmacists
  • Pharmacy directors

Qualifications:

  • PharmD
    • Residency or Fellowship: Optional
  • Skills:
    • Time management
    • Self-motivation
    • Time management
    • Strong self-learner
  • Experience:
    • Field experience
    • Proficiency in Managed Care through health plan or health system involvement
    • Research experiences in health outcome in relation to economic standing

Medical Science Liaison

General Responsibilities:

Responsibilities involve meeting with payers or providers to provide a detailed understanding of drugs by presenting clinical trials, clinical data, and info pertaining to special populations. Work up and update drug profiles for providers while staying updated with pipeline drugs and advancement in treatments.

Day-to-day or week-to-week schedule:

  • Remotely work from home
  • Meet with healthcare experts as needed basis
  • Travel to educational medical conferences (local, regional, or national)

Interactions:

  • Healthcare providers
  • Regional Accounts and Sales Team

Qualifications:

  • PharmD
    • Residency or Fellowship:Fellowship
  • Skills:
    • Strong oral and written communication
    • Data analyzation and comprehension
    • Ability to multitask
  • Experience:
    • Fellowship experience

Managed Care Liaison

General Responsibilities:

In the role of a Managed Care Liaison, the responsibilities include providing clinical knowledge to provider groups of drugs for a particular disease state. The clinical knowledge ranges from analyzing economic health data, outcome studies, post marketing studies, and safety data.

Day-to-day or week-to-week schedule:

  • Mainly work from home
  • Travel 3-4 times a week to meet with providers groups

Interactions:

  • Health Plans
  • PBMs
  • Provider Groups

Qualifications:

  • PharmD
    • Residency or Fellowship: Both are not required, but recommended.
  • Skills:
    • Strong written and oral communication
    • Ability to multitask
    • Highly self-motivated
  • Experience:
    • Fellowship experience
    • Managed care experience (helpful, but optional)

Medical Affairs

Medical Affairs sits within commercial organizations but is concerned with post-approval activities. Roles are there to provide scientific and clinical support for commercial products. Information is based upon published literature.

Account Management

General Responsibilities:

The responsibilities of an account manager involves taking care of patients on a different level. The work focuses on providing affordable access through PBMs on the industry side.

Day-to-day or week-to-week schedule:

  • Work through the process of making sure drugs are covered
  • Work with PBMs on formulary by researching and presenting strategic changes that would affect the products
  • Translate any changes and interpret them for corporate office or stakeholders
  • Help create awareness in product/drug class use for physicians/pharmacists

Interactions:

  • PBMs
  • Health plans
  • Corporate office
  • Healthcare providers

Qualifications:

  • PharmD: Optional
    • Residency or Fellowship: Optional
  • Skills:
    • Critical thinking
    • Networking
    • Problem solving
    • Negotiating
  • Experience:
    • People of different backgrounds of account management
    • Exposure to working with PBMs and Pharmaceutical Industries

Commercial

Formulary involvement with PBMs from the industry role through research and implementation of strategies affecting products.

Regulatory Affairs and Compliance

General Responsibilities:

The position of Regulatory Affairs and Compliance consists of responsibilities of providing guidance and strategy for drug development in a regulatory perspective and thriving strategy of clinical development programs. The position also works towards efficiency and compliance with all the regulations by the health agencies.

Day-to-day or week-to-week schedule:

  • Reviewing or preparing documents for regulatory agencies
  • Reports or providing information from the studies and communicate the evidence found
  • Meetings – internal and external
  • Internal with teams
  • External team members from agencies or other companies

Interactions:

  • Internal teams within the company
  • External team members from other agencies or companies

Qualifications:

  • PharmD: Not necessarily. Bachelors in a science background is required.
    • Residency or Fellowship: Highly recommended
  • Skills:
    • Leadership
    • Teamwork
    • Communication
    • Task management
  • Experience:
    • Scientific and clinical background
    • Learning the language

Legal

Strategy for drug development is done through a regulatory perspective to ensure compliance with health agencies.