• Assists in development and supervises the drug utilization and prior authorization review program. • Develops and implements pharmacy cost containment strategies tailored to the specific situations and patterns of the enterprise, specific regions, and large accounts. • Drafts pharmaceutical criteria and performs other activities in support of the enterprise prior authorization program. • Keeps up-to-date on medication information, contributing to the identification of pharmacy program best practices, collaborating with Medical Directors, leadership, and clinical department as a subject matter expert (SME). • May be responsible for conducting the second level review for medical and pharmacy benefit medication prior-authorizations, exceptions, and medical necessity reviews submitted to the plan. • May be responsible for ensuring appropriate alignment of medical policies and configuration for claims processing and utilization management. • Performs other duties as assigned. • Prepares and presents reports, data and analyses on the utilization and cost trends for enterprise lines of business, specific regions, and large accounts. • Provides leadership and advice on developing and implementing pharmacy reimbursement, claims processing policies and procedures, and pharmacy vendor selection. • Reviews and interprets coverage across assigned line(s) of business to determine what type of review is required and works with requesting providers, corporate medical directors, and other internal staff, as appropriate, in determining whether a specific case presentation meets the criteria for approval according to the specific coverage criteria. • Serves as a liaison to individual pharmacists, professional pharmacy organizations, internal committees, case management, medical management, and other providers on pharmacy issues. • Supports pharmacy initiatives for member, provider, and client satisfaction. • Uses clinical knowledge and independent critical thinking skills towards interpreting criteria, policies, and procedures to make determinations on prior approval reviews and retrospective reviews and/or pharmacy consultations within case management. • Uses knowledge of the pharmacy and/or medical benefit to communicate with, and provide recommendations to Care Management nurses, social workers, and medical directors. • Uses knowledge of the pharmacy and/or medical benefit to ensure our members receive their medications in a timely fashion, avoiding delays in treatment.

• Make outreach calls to members to address care gap issues. • Identify root causes for medication adherence issues and provide education to help resolve the problems. • Help members be set up for mail order prescriptions and handle follow-up mailings. • Confirm members’ current medications and identify discrepancies. • Provide administrative support for Performance Programs and other pertinent departments for collaboration on Star, HEDIS and P4P initiatives. • Maintain the internal tracker with dates and activities summarized and provide regular reporting on patients who are /are not at target goals based on CMS Star metrics. • Communicate with physician offices to clarify prescription orders, follow up on pharmacist recommendations on medications or fax communications. • Be proficient in Excel with ability to sort and filter cases based on priority. • Maintain reference documents related to the assigned role. • Follow up with appropriate personnel (both internally and externally) when problem arises. • Conduct ad-hoc projects, batch mailings/ faxing and follow-up to close gaps. • Create reports to track progress and intervention outcomes. • Participate in pharmacy orientation programs, pharmacy staff meetings, in-service educational programs and other functions as required by the pharmacy department. Complete required training, as assigned, within the established timeframes. Maintains regular attendance according to established policies. • Perform other job-related duties as assigned.

• Remote order entry and CPOE order evaluation and verification • Ensure timely acquisition and renewal of team assigned pharmacy staff licenses • Physician and nursing consultations • Clinical medication dosing services • Review and monitoring of profiles and lab values for therapeutic outcomes • Coordinates access to medications according to facility policy and procedures, and in compliance with state and federal laws and regulations

• Verify Prescription Accuracy: Ensure prescriptions are accurate, complete, and compliant with applicable regulations before dispensing. • Perform Drug Utilization Reviews: Review prescribed medications for safety, efficacy, and appropriateness based on patient history and current medications. • Collaborate with Healthcare Providers: Work closely with prescribing physicians and healthcare teams to clarify medication orders and resolve discrepancies. • Patient Safety & Compliance: Ensure that medications are prescribed for the right patient, in the right dose, and via the appropriate route of administration. • Monitor Medication Interactions: Identify potential drug-drug, drug-food, or drug-disease interactions and take corrective actions as necessary. • Maintain Records: Ensure that prescription records are accurately maintained and comply with all applicable state and federal regulations. • Stay Current with Pharmacy Regulations: Adhere to all relevant pharmacy practice laws, standards, and guidelines, including updates to drug formularies. • Provide Support as Needed: Assist with administrative tasks, such as medication-related inquiries, when required to improve overall workflow and patient care. • Contribute to Process Improvement: Provide insights and recommendations for optimizing prescription verification processes to enhance patient safety and operational efficiency.