Clinical Pharmacy Specialist (Remote)- Prior Authorization Team!

UPMC•Pittsburgh, PA

1d•Remote

About The Position

UPMC Health Plan is seeking a full-time Clinical Pharmacy Specialist to join the Prior Authorization Team within the Pharmacy Services department. This is a remote position with daylight hours (8:00 a.m. - 5:00 p.m. EST). The role involves providing clinical pharmacy expertise to manage the pharmacy benefit, including utilization management and the prior authorization and appeals process for medications. Services must comply with state and federal regulations (NCQA, CMS) and uphold UPMC Health Plan's mission and policies. The ideal candidate will demonstrate professionalism and commitment to UPMC HP goals.

Requirements

Must be licensed in PA or eligible for licensure by examination or reciprocity.
Registration as a registered pharmacist (RPh) in the Commonwealth of Pennsylvania.
Legally authorized to work in the United States without future sponsorship.
Bachelor of Science Degree in Pharmacy and/or Doctor of Pharmacy Degree (Pharm.D.) from an accredited U.S. School of Pharmacy.
Effective communication skills, both written and oral.
Strong analytical ability and organizational skills.
Computer literacy for pharmacy programming, word processing, and data management.
Continuing Education requirements met each bi-annual cycle for re-licensure (minimum 30 hours every 2 years).
Act 34 clearance.

Nice To Haves

Prior pharmacy experience in a retail setting.
Management experience.
Experience in pharmacy benefit management, insurance, managed care.
Knowledgeable in therapeutic interventions and other cost containment programs.
Experience with claims adjudication, therapeutic substitution interventions, dose optimization, and other cost containment programs.
Completion of a managed care residency or 1-3 years of managed care experience.

Responsibilities

Perform clinical review of Prior Authorization, Step Therapy, Quantity Limit, and other pharmacy utilization management requests according to quality, timeliness, and efficiency standards.
Critically review pharmacy utilization management requests for approval/denial against standard clinical criteria and regulatory approved policies.
Participate in a clinical call queue to address inquiries from internal and external stakeholders regarding the exception process, ensuring timely, accurate, and professional responses.
Participate in the pharmacy appeals process by reviewing denied cases and serving as committee representation at fair hearings.
Contribute to other operational initiatives as needed.
Foster and maintain collaborative relationships with internal and external customers.
Perform job duties independently, reliably, efficiently, accurately, and professionally while supporting a virtual team concept.
Demonstrate strong drug information skills to research drugs and disease states for complex utilization management reviews and other responsibilities.
Utilize a home office setup that ensures client and patient confidentiality.
Maintain a foundational understanding of requirements from the Pennsylvania Department of Human Services (DHS), Centers for Medicare & Medicaid Services (CMS), Pennsylvania Insurance Department (PID), and the National Committee for Quality Assurance (NCQA) related to clinical operational functions.
Participate in assigned meetings, committees, and work groups.
Mentor students, residents, and other pharmacists (if applicable).