What Does a Managed Care Pharmacist Do?

A managed care pharmacist works within a managed care program to deliver effective and efficient services to patients. In these programs, care providers coordinate to maintain a high degree of communication between each other. This can help them cooperate on patient care to achieve the best possible outcome. The work can involve direct interactions with patients as well as care providers and insurance companies.

As a representative of a managed care organization, a managed care pharmacist can conduct utility reviews into different kinds of medications and treatment protocols. These reviews can be used to set policy and process claims. If a claim for a medication does not seem justified, it can be denied under the policy. Customers can request an audit, which may be supervised by the managed care pharmacist, to determine if the denial was fair. In this evaluation of a claim, the pharmacist might consider available alternatives and their efficacy.

This can also include reviewing new medications and changes in the way medications are utilized. A managed care pharmacist needs to keep up with trends in the industry to make sure clients are served well. Pharmacies that belong to the organization may interact with the managed care pharmacist when they set policy, negotiate with drug companies for bulk pricing, and engage in other activities. The creation of consistent and effective policies can also extend to activities like creating a protocol for advising patients on new prescriptions, catching drug interactions, and managing patient files.

In a complex medical case, care providers may work with the managed care pharmacist and other skilled medical professionals to develop a treatment plan. They can consider policies and procedures at the managed care company, along with the best needs of the patient. Financial matters can be a concern, as such companies want to operate efficiently, but sometimes the needs of the patient outweigh these. A care plan may involve complex or expensive treatments because these would offer the most benefits. Managed care pharmacists help to decide which treatments should be offered, and how.

Continuing education may be necessary to maintain a license to practice and remain competitive in the industry. This can include attending conferences and courses, in addition to subscribing to trade medications. Some managed care pharmacists are actively involved in research and publishing to improve patient outcomes and managed care services. They can also work in clinical environments to retain skills, audit member pharmacies, and test out proposed policies on the ground before implementing them.