Pharmacist I, Clinical Prior Authorization

Navitus Health Solutions, LLC•,

22h•$101,335 - $126,669•Remote

About The Position

Navitus is adding a Pharmacist I, Clinical Prior Authorization to support its clinical pharmacy programs. The role performs prior authorizations and drug utilization review activities, including concurrent, retrospective, and prospective reviews, and supports Customer Care on clinical calls requiring pharmacist intervention. It interfaces with physicians, pharmacists, and specialty pharmacy providers about beneficiaries’ benefits and therapeutic interventions, and reviews health survey and utilization data for program management and development. The pharmacist contributes to clinical programs such as Health Management, Drug Utilization Review, formulary development, and Prior Authorization, with the aim of promoting appropriate, high-quality, cost-effective drug therapy and improving program efficiency, accuracy, and appropriateness. The role reviews coverage requests that are not clearly approvable under established criteria, makes coverage denial determinations, monitors the quality and efficiency of coverage decisions, and supports clinical content and program implementation. The position is remote, with work restricted to residents of the states and jurisdictions listed in the posting.

Requirements

Bachelor’s degree in Pharmacy or PharmD.
Current, unrestricted Registered Pharmacist license in the state of residence, or ability to gain reciprocity within four months when required by state law or client contracts; additional state pharmacy licenses may be required based on business needs.
Maintain continuing education credits required to keep licensure active.
Exceptional clinical skills and ability to apply sound clinical judgment in a variety of situations.
Ability to reason and translate clinical information for clinical systems and clinical and non-clinical audiences.
Problem-solving skills, including identifying challenging situations and creating and implementing solutions.
Attention to detail to ensure projects are clinically, editorially, and systems accurate and operationalizable.
Ability to interact consistently, cooperatively, and respectfully with other employees.

Nice To Haves

Two years’ work experience in a clinical setting, or a clinical or managed care pharmacy practice residency.
Knowledge of the PBM industry, formulary management, pharmacy claims, and managed care principles and practices.
Proficiency in drug literature and clinical trial evaluation, including use of electronic databases such as Micromedex, Medline, and the Internet.
Proficiency in Microsoft Word, Excel, and PowerPoint, including tables, charts, and figures.

Responsibilities

Perform prior authorizations and duties related to concurrent, retrospective, and prospective Drug Utilization Review.
Support Customer Care with clinical calls requiring pharmacist intervention.
Interface with physicians, pharmacists, and specialty pharmacy providers regarding beneficiaries’ benefits and therapeutic interventions.
Review health surveys and utilization data for program management and development.
Support and provide input to Health Management, Drug Utilization Review, formulary development, and Prior Authorization programs to encourage appropriate, high-quality, cost-effective drug therapy and identify opportunities for program improvement.
Participate in the Coverage Determination process by reviewing requests that are not clearly approvable based on specified criteria, making coverage denial determinations, and identifying their name, title, and Navitus responsibility in relation to drug utilization management administration.
Monitor the quality and efficiency of the Coverage Determination process, including coverage criteria, denial language, and communication with prescribers.
Provide input to clinical content for new programs and maintenance of existing programs.
Complete annual URAC training requirements.
Facilitate communication and education for clients, members, and internal staff regarding clinical issues and objectives.
Support operational departments with implementation of PBM programs and daily operations in support of member and patient quality of care.
Support and provide clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee.
May review health care survey data for Medicare Part D qualified participants, conduct phone consultations with Medicare Part D enrollees, help document calls, and designate enrollees for repeat interaction.
Participate in, adhere to, and support compliance program objectives.
Perform other duties as assigned.