Clinical UM Pharmacist

HealthFirst•Remote - NY, NV

4d•$88,700 - $149,430•Hybrid

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 in the state of New York with a license in good standing.
Minimum of 1 year experience conducting prior authorization reviews
Strong clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews
Strong clinical writing and verbal skills
Demonstrated critical thinking and problem-solving skills.
Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits
Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities
Licensed pharmacist in the state of NY in good standing.

Nice To Haves

PGY1 Managed Care Residency (optional)
Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations.
Ability to lead 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
Perform and present drug utilization reviews (DUR) on medical benefit medications to assess clinical appropriateness, safety, and cost-effectiveness
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 present on trends, ideas for efficiency/innovation, and medical spend
Ability to work well in a team environment and be a team player
Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.
Additional duties as assigned or required