Pharmacist I – Clinical Prior Authorization

This is a fully remote position, open to applicants in Alabama, +34 more locations.

📋 Description

• Conduct Prior Authorizations.

• Perform tasks associated with Drug Utilization Review, encompassing concurrent, retrospective, and prospective components.

• Assist Customer Care by handling clinical calls that necessitate pharmacist intervention.

• Collaborate with physicians, pharmacists, and specialty pharmacy providers concerning beneficiaries’ benefits and therapeutic interventions.

• Assess and analyze health surveys and utilization data for program management and development.

• Contribute to clinical programs such as Health Management, Drug Utilization Review, Formulary development, and Prior Authorization initiatives.

• Engage in the Coverage Determination process by evaluating requests that are not clearly approvable based on established criteria, making coverage denial decisions, and identifying their role in drug utilization management program administration.

• Oversee the quality and efficiency of the Coverage Determination process, including coverage criteria, denial language, and communication with prescribers.

• Offer input on the clinical content of new programs and maintain existing programs.

• Fulfill annual URAC training requirements.

• Facilitate communication and education for clients, members, and internal staff regarding clinical issues and objectives.

• Assist operational departments with the implementation and daily management of PBM programs in support of member/patient quality of care.

• Provide clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee.

• Review healthcare survey data for Medicare Part D participants and/or conduct phone consultations with enrollees; document calls and designate enrollees for follow-up interactions.

• Perform additional duties as assigned.

⛳️ Requirements

• A minimum of a bachelor's degree in Pharmacy or Pharm D.

• Current, unrestricted licensure as a Registered Pharmacist in the state of residence, or the ability to obtain reciprocity within 4 months, depending on state laws or client contracts.

• Additional State Pharmacy Licenses may be necessary based on business needs.

• Continuous maintenance of education credits is required to uphold active licensure.

• A minimum of two years of experience in a clinical setting, or completion of a clinical or managed care pharmacy practice residency is preferred.

• Familiarity with the PBM industry, formulary management, pharmacy claims, and managed care principles and practices is desirable.

• Strong clinical skills and the capacity to apply sound clinical judgment across various situations is essential.

• Proficiency in drug literature and clinical trial evaluation, including experience with electronic databases (e.g., Micromedex, Medline, Internet) is preferred.

• Ability to interpret and convey clinical information appropriately for clinical systems and both clinical and non-clinical audiences.

• Problem-solving abilities, including the capability to identify challenging situations and develop and implement effective solutions.

• Attention to detail to ensure that projects are clinically, editorially, and systemically accurate and can be operationalized.

• Proficiency in MS Word, Excel, and PowerPoint, including the ability to create tables, charts, and figures is preferred.

• Engage in, comply with, and support the objectives of the compliance program.

• Ability to consistently interact cooperatively and respectfully with colleagues.

🏝️ Benefits

• Comprehensive benefits package for Health, Dental, and Vision insurance.

• 20 days of paid time off.

• 4 weeks of paid parental leave.

• 9 paid holidays.

• 401K company match of up to 5% with no vesting requirement.

• Adoption Assistance Program.

• Flexible Spending Account.

• Educational Assistance Plan and support for Professional Memberships.

• Referral Bonus Program – up to $750!

• STAR Bonus % (At Risk Maximum): 10.00.