Pharmacist I, Clinical Prior Authorization

Navitus Health Solutions, LLC

2d•Remote

About The Position

Navitus Health Solutions is seeking a Pharmacist I, Clinical Prior Authorization to join their team. The role involves performing Prior Authorizations, Drug Utilization Review (concurrent, retrospective, and prospective), and supporting Customer Care with clinical calls. The Pharmacist I will also interface with physicians, pharmacists, and specialty pharmacy providers regarding benefits and therapeutic interventions, and review health surveys and utilization data for program management and development.

Requirements

A minimum of a bachelor’s degree in Pharmacy or Pharm D.
Current unrestricted licensure as an RPh in the State of the home office of the pharmacist or the ability to gain reciprocity within 4 months of employment is required
Exceptional clinical skills and ability to apply sound clinical judgment to a variety of situations is necessary
Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences
Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
Requires attention to details to assure projects are clinically, editorially, and systems accurate and can be operationalized
Participate in, adhere to, and support compliance program objectives
The ability to consistently interact cooperatively and respectfully with other employees

Nice To Haves

Two years’ work experience in a clinical setting, or clinical or managed care pharmacy practice residency preferred
Knowledge of PBM industry, formulary management, pharmacy claims and managed care principles and practices desired
Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline, Internet) preferred
Proficiency in MS Word, Excel, Power Point including tables, charts and figures preferred

Responsibilities

Support and input to clinical programs such as: Health Management, Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high quality, cost effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place
Participate in the Coverage Determination (Certification, Prior Authorization, Medical Exception, Exception to Coverage, etc.) process by reviewing all requests which are not clearly approvable based on specified criteria (algorithms), making all coverage denial determinations, and identifying themselves by first name, title, and responsibility at Navitus in relation to drug utilization management program administration
Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers
Provide input to clinical content of new programs and for maintenance of existing programs
Complete all annual URAC training requirements
Facilitation of communication and education to clients, members, and internal staff regarding clinical daily issues and objectives
Provide support to operational departments on the implementation of various PBM programs and daily functioning in support of member/patient quality of care
Support / 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 and/or perform phone consultations with Med-D enrollees; aid in documentation of calls; designate enrollees for repeat interaction
Other duties as assigned