Per Diem Clinical Pharmacist

Point32Health-posted 6 days ago
Mid Level
Remote • Canton, MA
1,001-5,000 employees
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Under the direction of the Pharmacy Utilization Management (UM) Supervisor, the Per Diem Clinical Pharmacist is responsible for reviewing, processing and managing the daily caseload of pharmacy prior authorization (PA) requests for coverage determinations (CD), and exceptions. The Per Diem Clinical Pharmacist ensures timely disposition of reviews for CD and exceptions by adherence to established timeframes. The Per Diem Clinical Pharmacist consults as required with Medical Directors (MD) on prior authorization that fails to meet drug prior authorization (PA) criteria for coverage.

  • Performs case reviews in automated prior authorization (Auto PA) tools and guides the case through the entire process to either approval or denial to ensure all coverage determinations and notices are consistent with applicable regulatory and accreditation requirements and turnaround times
  • Provides all aspects of clinical support needed to perform drug prior authorization (PA) requests and consults as required with Medical Directors (MD) on cases that fail to meet coverage criteria
  • Communicates daily with members, providers and other external customers regarding status and disposition of cases
  • Oversees and addresses any quality issues with pharmacy technicians and confer with other clinical pharmacist on review questions
  • Communicate with UM staff and providers when issues arise regarding policy interpretation, potential access availability, or other quality assurance issues to ensure that members receive coverage determinations within timelines developed by all accrediting and regulatory guidelines
  • Facilitates communication between Pharmacy UM department and other internal departments by acting as a liaison or committee member on the development or implementation of new programs
  • Performs other roles/duties and projects as assigned by the Pharmacy UM Supervisor or Director
  • Licensed to practice pharmacy with pharmacy degree required
  • Current and valid pharmacist license
  • Doctor of Pharmacy (PharmD)
  • A minimum of 3 years full-time experience as a pharmacist, preferably PBM and/or managed care setting.
  • Strong interpersonal skills with ability to manage build relationships and influence member behavior
  • Autonomous practitioner with strong critical thinking skills
  • Articulate with ability to present clinical and administrative information concisely
  • Independent problem-solving ability with ability to manage conflict and build consensus
  • Organizational skills with ability to prioritize based on deliverable timelines, member needs and contract requirements
  • Ability to practice in an interdisciplinary team-based model
  • Must be able to work under normal office conditions and work from home as required.
  • Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
  • May be required to work additional hours beyond standard work schedule.
  • PharmD from an ACPE-accredited school of pharmacy strongly desired
  • Expert knowledge of the principles and practices of pharmaceutical science.
  • Working knowledge of Federal and state controlled substance and pharmacy laws, rules, and regulations.
  • Knowledge of drug coding (NDC, GCN, GPI and USC) and NCPDP claims adjudication systems.
  • Previous working knowledge of PAHub, RxClaim, and MedHOK system a plus.
  • Knowledge of or experience with Medicare Part B & D, Medicaid, and Drug Utilization Management.
  • Prior authorization experience, including reviewing drug use criteria for medication approval.
  • Medical, dental and vision coverage
  • Retirement plans
  • Paid time off
  • Employer-paid life and disability insurance with additional buy-up coverage options
  • Tuition program
  • Well-being benefits
  • Full suite of benefits to support career development, individual & family health, and financial health
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