Manager, Clinical Pharmacist UM

HealthFirst•Herminie, PA

7d•$88,700 - $149,430•Hybrid

About The Position

The Manager, Clinical Pharmacist UM is responsible for the review of prior authorization requests for medications requested under the medical benefit. Additionally, the role is responsible for the hands-on leadership over the UM Pharmacy team and all related people management responsibilities. This will be a Hybrid position that will need to report into 100 Church Street.

Requirements

Pharmacy degree from an accredited school of pharmacy
Registered Pharmacist with a license in good standing.
Minimum of 3-year experience conducting prior authorization reviews.
Minimum of 3-year experience managing multifaceted and dynamic teams.
Strong clinical knowledge of pharmaceuticals and disease states to conduct prior authorization reviews.
Strong clinical, writing, verbal and presentation 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.

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.
Demonstrated professionalism and leadership skills along with ability to develop, direct, and support a team.
Time management, critical/creative thinking, communication, and problem-solving skills
Adept at planning, organizing, and executing.
Ability to build and enhance team productivity and effectively manage performance as well as set and achieve goals.
Intermediate Outlook, Word, Excel, and PowerPoint skills

Responsibilities

Responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly reports for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine.
Work with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions
Supervises, evaluates, and coordinates daily team operations and responsibilities to ensure that departmental productivity goals are met regarding quality, timeliness, accuracy, and consistency.
Allocates, monitors, and controls resources while delegating and monitoring workloads.
Assists Sr. Manager with reviewing team performance.
Implements and supports continuous process improvement and quality initiatives.
Exercises judgment within defined procedures and policies to determine appropriate actions and administers departmental policies.
Develops and monitors team goals; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and empowerment to make informed decisions.
Assists Sr. Manager in directing, training, and developing team members by embodying the Trailblazer mindset and leading others by example.
Builds and develops relevant business relationships, critically thinks about departmental problems, and makes informed recommendations as to how to resolve issues.
Attend, schedule, and present in internal and external departmental meetings.
Participates in preparation and conducting of regulatory site surveys [NYS Department of Health, Centers for Medicare and Medicaid Services (CMS), Dept of Insurance].
Perform prior authorization reviews as set forth by CMS and/or NYSDOH.
Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH.
Monitor and review prior authorization requests for medications.
Calculate appropriate billable units based on dosing based, indication, weight, BMI and other clinical considerations.
Develop clinical criteria and medical policies for the review of medications.
Ensure all clinical criteria follows 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.
Review monthly reports and provide feedback on trends, ideas for efficiency, and innovation.
Ability to work weekends, holidays, and as needed to support departmental needs.