• Medical Case Manager- Pharmacy

    Job Location(s) US-Any
    Job ID
    # of Openings
    Managed Care
    Job Type
    Regular Full-Time
  • Overview

    Position Summary:


    To utilize evidence based tools to evaluate the prescribed medications to ensure patient safety and quality standards are in alignment with best practice standards.


    Essential Duties and Responsibilities

    Performs clinical assessment via information in pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place.

    • Review patient claim and medication history with physician prescribing patterns.
    • Identify and evaluate overuse, underuse and misuse of prescribed medications
    • Evaluates need for and recommends alternative treatment.
    • Refer to Medical Director as necessary and document file and send letters as necessary to prescribing physician(s)
    • Negotiates appropriate level of care through use of medical and disability duration guidelines, adhering to quality assurance standards
    • Negotiates changes in pharmacy treatment plan with providers
    • Acts as a resource in consulting with the client, nursing staff, patient and claims examiners regarding pharmacy issues
    • Reviews clinical escalation alerts
    • Communicates effectively with claims examiner, client, vendor, supervisor and other parties as needed
    • Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards


    Additional Functions and Responsibilities

    • Demonstrates ability to meet administrative requirements, including productivity, time management and Quality Assurance standards
    • Maintain minimum billing and established template documentation standards adhering to URAC standards
    • Reporting billing hours in accordance with case activity and billing practices
    • Maintain Confidentiality- Knowledge of laws and regulations pertaining to HIPPA and PHI
    • Other job duties as assigned




    • Diploma, Associate or Bachelor’s degree in Nursing, Master’s level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred
    • Current, unrestricted nursing license (RN, LPN) or Pharmacist (PharmD, R.PH,) required
    • CCM, CPDM, COHN or CDMS certification preferred



    To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

    • Three or more years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions.
    • Knowledge of pharmaceuticals to treat pain, pain management and or drug rehabilitation process
    • Three or more years of Managed Care and or Worker’s Compensation experience
    • Background in state worker’s compensation law and practices desirable
    • Ability to solve practical problems and deal with a variety of variables 
    • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills. 
    • Excellent interpersonal skills and excellent organizational skills.
    • Ability to set priorities and work independently is essential
    • Proficient with Microsoft Office applications including Word, Excel, and Power Point



    Essential Equipment: Desk, Telephone/Fax, Computer Keyboard, Mouse, System Applications

    Essential Tools: Pens, pencil, computer, Keyboard

    Essential Vehicles: N/A 


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