Clinical UM Pharmacist

HealthFirst

About The Position

The Clinical UM Pharmacist is a dynamic position responsible for the review of prior authorizations for medications requested under the medical benefit. Additionally, the Clinical UM Pharmacist is responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly report for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine. The Clinical Pharmacist works directly with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions.

Requirements

Pharmacy degree from an accredited school of pharmacy
Registered Pharmacist with a state license in good standing.
Work experience conducting prior authorization reviews
Clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews
Work experience requiring written and verbal clinical communication that is clear, concise, grammatically correct, and professional
Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits

Nice To Haves

PGY1 Managed Care Residency
Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations
Demonstrated critical thinking and problem-solving skills
Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities
Experience leading large and small working meetings
PC Skills with Microsoft Outlook, Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables)

Responsibilities

Monitor and review prior authorization requests for medications
Calculate appropriate billable units based on dosing, indication, weight, BMI and other clinical considerations
Develop clinical criteria and medical policies for the review of medications
Ensure all clinical criteria is in compliance with Center of Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH)
Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH
Work across departments as needed to complete Utilization Management reviews
Review monthly reports and provide feedback on trends, ideas for efficiency, and innovation
Ability to work well in a team environment and be a team player
Additional duties as assigned or required
Assists in regulatory and compliance audits for all plans.
Ensure all activities are conducted in compliance with regulations.