Clinical Pharmacist, Utilization Management

Univera Healthcare•Rochester, NY

10h

About The Position

Summary: This position is responsible for and participates in a wide range of provider, patient, and employer initiatives and programs. The pharmacist supports all of our lines of business which include Medicare, Commercial, Exchange (Marketplace) and Medicaid. The focus of the UM Pharmacist is to manage the quality, appropriateness, safety and cost of medications for our members through the medical management of drugs across our pharmacy and medical benefits. Essential Accountabilities: Level I Conducts drug prior authorization, exception and medical necessity reviews. Works with requesting providers or internal staff to determine whether the submitted clinical information and patient presentation meet the criteria for approval according to the drug policy, formulary availability, and specific coverage criteria. Conducts first line appeal and grievance reviews for medical and pharmacy drugs in accordance with compliance standards. Conducts comprehensive reviews and documentation of findings for submission to the medical director for final determination, as required by law. Provides comprehensive support directly to providers and pharmacies, as needed, to expedite the treatment of our members. Communicates effectively with our community providers for case discussions on clinical call backs, providing next step options based upon line of business analysis and level of reviews already completed. Provides drug information support to our medical directors during clinical calls with prescribers. Presents quarterly CAU review and analysis to the clinical team and compliance department. Participates in monthly case consistency meetings in collaboration with different business areas. Contributes to the maintenance and addition of relevant clinical information for the UM team’s SharePoint site. Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs. Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. Regular and reliable attendance is expected and required. Performs other functions as assigned by management. Level II (in addition to Level I Accountabilities) Maintains assigned policies (such as infertility, compounding, and off label reviews) keeping up with current clinical guidance and company strategy. Provides guidance, instruction and mentoring of pharmacy and other health care students involved in experiential rotations in the department. Takes lead role in audits, as necessary. Facilitates the onboarding and training of new hire pharmacists. Collaborates with Decision Criteria Coordinator to maintain and update decision criteria and denial language. Research subrogation questions and determine whether retroactive payment would be appropriate. Level III (in addition to Level II Accountabilities) Identify and troubleshoot issues arising during use of care management tools. Guides level I/II teammates on clinical decision-making and UM process insight to resolve day-to-day issues and ensure the team’s work is compliant, consistent, and of high quality. Revises and organizes key documents used by the UM staff to support case consistency. Conducts monthly quality assurance review for pharmacy reviews and identifies issues and cases for coaching and process changes. Presents on meetings to share information and processes with fellow team members. Participates in internal policy discussions with supervisors to ensure consistency. Ensure that affiliated team members receive necessary support. Take lead role in audits, as necessary. Participates in cross-functional company-wide workgroups.

Requirements

Unrestricted and current NYS Licensed Pharmacist
Pharm.D. In lieu of a Pharm.D., a Bachelors in Pharmacy is required.
Managed care experience is strongly preferred, especially experience in utilization management.
In lieu of managed care experience, proven record of successful experience in a high-volume retail or hospital pharmacy is accepted.
Experience in an organized health care setting or in a practice environment with direct physician interaction, data analysis and/or benefit interpretation process experience is strongly preferred.
Must possess strong customer service orientation and the ability to interface effectively with internal and external customers.
Fundamental knowledge of drug information process/references and ability to conduct drug and disease information research required.
Able to serve as a knowledgeable liaison to internal and external organizations, to foster positive relationships with our vendor/partners, and to appropriately advocate for the corporation.
Strong computer skills.
Proficient knowledge of Microsoft Word and Excel.
A minimum of two years’ experience in a managed care setting, specifically in utilization management.
Experience and skillset in a therapeutic or pharmacy management area that is critical to the Health Plan’s strategic program.
A minimum of five years’ experience in in a managed care setting, specifically in utilization management.
Attained sufficient proficiency, skills and expertise to manage and be accountable for a specific area of business, such as specialty drugs, Medicare drug, rebate management, audit functions, etc.
Demonstrate exceptional understanding of process and procedure utilizing the care management tools.
Consistently demonstrates an in depth understanding of utilization management best practices, DLPs and guidance.

Responsibilities

Conducts drug prior authorization, exception and medical necessity reviews.
Works with requesting providers or internal staff to determine whether the submitted clinical information and patient presentation meet the criteria for approval according to the drug policy, formulary availability, and specific coverage criteria.
Conducts first line appeal and grievance reviews for medical and pharmacy drugs in accordance with compliance standards.
Conducts comprehensive reviews and documentation of findings for submission to the medical director for final determination, as required by law.
Provides comprehensive support directly to providers and pharmacies, as needed, to expedite the treatment of our members.
Communicates effectively with our community providers for case discussions on clinical call backs, providing next step options based upon line of business analysis and level of reviews already completed.
Provides drug information support to our medical directors during clinical calls with prescribers.
Presents quarterly CAU review and analysis to the clinical team and compliance department.
Participates in monthly case consistency meetings in collaboration with different business areas.
Contributes to the maintenance and addition of relevant clinical information for the UM team’s SharePoint site.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Maintains assigned policies (such as infertility, compounding, and off label reviews) keeping up with current clinical guidance and company strategy.
Provides guidance, instruction and mentoring of pharmacy and other health care students involved in experiential rotations in the department.
Takes lead role in audits, as necessary.
Facilitates the onboarding and training of new hire pharmacists.
Collaborates with Decision Criteria Coordinator to maintain and update decision criteria and denial language.
Research subrogation questions and determine whether retroactive payment would be appropriate.
Identify and troubleshoot issues arising during use of care management tools.
Guides level I/II teammates on clinical decision-making and UM process insight to resolve day-to-day issues and ensure the team’s work is compliant, consistent, and of high quality.
Revises and organizes key documents used by the UM staff to support case consistency.
Conducts monthly quality assurance review for pharmacy reviews and identifies issues and cases for coaching and process changes.
Presents on meetings to share information and processes with fellow team members.
Participates in internal policy discussions with supervisors to ensure consistency.
Ensure that affiliated team members receive necessary support.
Take lead role in audits, as necessary.
Participates in cross-functional company-wide workgroups.