Clinical Specialist

MedImpact•San Diego, CA

13h•$52 - $94•Onsite

About The Position

The Clinical Specialist manages accessibility, quality, and cost-effectiveness of drug and medical therapy for members and providers. This position focuses on initiating, supporting, and continuing cost-effective, rational drug, and disease therapy, utilizing distinct but inter-related management and cross-departmental functions.

Requirements

PharmD and 3+ years’ experience or equivalent combination of education and experience, and 1 year of SME in respective areas
To perform this job successfully, an individual should have knowledge of Microsoft Office Suite Word Processing software.
Current, unrestricted Registered Pharmacist license in any state of the United States.
Excellent working knowledge of all types of pharmacy services with an emphasis on the managed health care environment.
Expertise in clinical application of pharmacy practice.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry.
Ability to read and comprehend simple instructions, short correspondence, and memos.
Ability to write simple correspondence.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Composure
Decision Quality
Organizational Agility
Problem Solving
Customer Focus
Drive for Results
Peer Relations
Time Management
Dealing with Ambiguity
Learning on the Fly
Political Savvy

Responsibilities

Responsible for providing clinical review support services to client plan(s) contracting for clinical services.
Support services also include, but not limited to, clinical review, analysis, recommendation, decision and documentation of prior authorization requests, medical exception requests, and requests as required by client contracts and Utilization Management delegation agreements.
Review medication request guidelines for clinical appropriateness and operational efficiency.
Assist in the revision and creation of new or existing medication request guidelines as indicated.
May consult regarding a PA request directly with a client representative or an internal Subject Matter Expert or contact a dispensing pharmacist, prescriber or prescriber representative to obtain additional information.
Provide drug information support.
The position may also need to follow general guidance from the client on the handling of specific request types (non-formulary, quantity exceptions, etc.)
Research and provide clinical literature documentation to support prior authorization decisions as indicated.
Coordinate and assist with projects associated with prior authorization program development, implementation and internal and external communications.
Provide feedback to Prior Authorization Coordinators (PACs) regarding the processing of PA cases referred for clinical review. This includes PAs that do not follow proper protocol of initial reviews before sending to the Clinical Specialists.
Provide in-service education to PACs regarding topics such as PA guidelines, diagnoses commonly seen as part of the PA review process.
Handling Provider, Pharmacy and member calls to complete prior authorization and Peer to Peer requests based on client specific requirements
Assist with training to support growth of the Prior Authorization Department.