Clinical UM Pharmacist

This is a fully remote position, open to applicants in Alabama, +36 more states.

📋 Description

• Oversee and evaluate prior authorization requests for medications.

• Determine appropriate billable units based on dosing, indications, weight, BMI, and other clinical factors.

• Create clinical criteria and medical policies for medication assessments.

• Ensure that clinical criteria align with CMS and NYSDOH guidelines.

• Conduct research on drug information and uphold knowledge of drugs and disease states.

• Execute and present drug utilization reviews for medications covered by medical benefits.

• Complete prior authorization assessments within the timeframes set by CMS and/or NYSDOH.

• Collaborate with various departments to finalize Utilization Management reviews.

• Analyze monthly reports and present findings on trends, efficiency, innovative ideas, and medical spending.

• Support regulatory and compliance audits for all plans.

• Ensure that all activities adhere to applicable regulations.

• Perform additional tasks as assigned or required.

⛳️ Requirements

• A pharmacy degree from a recognized school of pharmacy.

• Must be a Registered Pharmacist in the state of New York with an active license in good standing.

• At least 1 year of experience in conducting prior authorization reviews.

• Comprehensive clinical knowledge of pharmaceuticals and various disease states.

• Excellent clinical writing and verbal communication skills.

• Proven critical thinking and problem-solving abilities.

• Familiarity with specialty pharmaceuticals and billing practices in both medical and pharmacy benefits.

• Enthusiasm for developing skills in a dynamic work environment.

• Understanding of Centers for Medicare and Medicaid Services regulations, including National and Local Coverage Determinations.

• Capability to lead both large and small working meetings.

• Proficient in Microsoft Outlook, Word, PowerPoint, and Excel, including experience with Pivot tables.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Incentive and recognition programs.

• Life insurance coverage.

• 401k contribution plans.

• Competitive salary and benefits package.