Clinical Pharmacist - Appeals and Operations - remote

Fallon Health • Worcester, MA

2d • Remote

About The Position

Fallon Health is seeking a Clinical Pharmacist to review and provide clinical decisions/recommendations for provider/member submitted appeals and grievances for medically administered medications as well as pharmacy related medications and items for all lines of business. This role will also analyze pharmacy data to assist with UM development and formulary development, and provide clinical assistance to pharmacy staff for daily operations. Fallon Health is a company that cares, prioritizing members and delivering equitable, high-quality, coordinated care. Founded in 1977 in Worcester, Massachusetts, Fallon Health is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We embrace and encourage diversity. Our mission is to improve health and inspire hope, striving to be the leading provider of government-sponsored health insurance programs in the region.

Requirements

• Current license to practice as pharmacist in Massachusetts without restriction
• 3 years, preferably with at least 1 year in a managed care environment; 1-2 years professional experience practicing as a clinical pharmacist.
• Recent experience related to member and/or provider appeals and drug coverage determinations is a plus.
• Able to evaluate clinical pharmacy data, coverage criteria and drug monographs.
• Able to understand and use computer databases, EMRs, Excel, Word, PowerPoint and others.
• Able to write and orally communicate clinical decisions to physicians and other healthcare personnel.
• Excellent communication skills, coordination, and planning skills along with an ability to interact with a variety of audiences to build collaboration and consensus.

Responsibilities

• Responsible for reviewing and providing clinical decisions/recommendations for provider/member submitted appeals and grievances for medically administered medications as well as pharmacy related medications and items for all lines of business.
• Collaborate with the Appeals & Grievance Department, Medical Directors, and Prior Authorizations vendors.
• Maintain turnaround times for all appeal and grievance reviews.
• Review appeal/grievance requests per plan-specific criteria, MassHealth-developed criteria, National Coverage Determinations, and Local Coverage Determinations, Evidence of Coverage, Member Handbooks.
• Follow regulatory rules and processes for Massachusetts, CMS, Medicaid, state Connector programs.
• Consult with internal and external stakeholders as needed.
• Consult with providers.
• Participate in managing clinical issues resolution; work with medical providers and vendors to coordinate and resolve member issues.
• Provide recommendations, as appropriate, to update current prior authorization criteria due to appeals and grievance data.
• Assist with formulary and criteria development for all lines of business.
• Participate in general drug information support for internal and external clients.
• Provide clinical assistance to pharmacy staff for daily operations.

Benefits

• Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed