Prior Authorization (PA) Pharmacist

Curative•Austin, TX

47d•Remote

About The Position

Prior Authorization (PA) Pharmacist Curative is reimagining health insurance - with $0 out of pocket costs and by reducing barriers to people seeking care. Help us create a better healthcare experience for our members by making it easy and intuitive for them to access the care they need. We believe in a clear, simple health plan that allows our members to get zero-cost in- network care anytime they need it. We want to put healthcare back in the hands of the patient and clinicians, with a focus on preventative care. Curative is rapidly growing and is raising the bar in what people expect from their health plan. While this role's focus is primarily prior authorizations and appeals, the pharmacist will also assist with formulary management, P&T committee, commercial benefit design, data integration, and support disease management initiatives such as diabetes and adherence. As Curative continues to have rapid growth, our business needs can change as we grow together. This is a REMOTE Position with RPh Licensure required in the state of residence.

Requirements

Possess strong analytical skills and detail oriented
Ability to work independently with minimal supervision
Understanding of claims processing and claims edits
Intermediate level proficiency with MS Office applications- Word, Power Point, Excel, and Access
Intermediate to advanced pharmacy drug recognition
Ability to work in a dynamic and fast-paced environment
2 years of experience with specialty medications or prior authorization
1 year of experience with PBM or Managed Care setting
Doctor of Pharmacy (Pharm D) degree.
Must possess an active RPh license within state of residence.

Nice To Haves

3 years as practicing pharmacist or 1 year as PGY-1 resident
2 years' experience in a Managed Care Setting
Knowledge of Medispan or First Data Bank and drug classification system
Understanding of Drug-Cost Analysis
BCPS or CSP certification

Responsibilities

Performs Prior Authorization reviews and coverage determinations as defined by pharmacy benefit design and established clinical treatment guidelines
Manages all level of clinical review from Adverse Determination, Appeals and IRO.
Support and manage health plan operations and ensures PBM aligns with benefit design
Write, review, and update PA guidelines for support of P&T committee and pharmacy benefit design
Acts as support to pharmacy technician and provides training and education where needed
Meets assigned metrics and TAT as defined by regulatory requirements within state or lines of business
Supports Disease Management initiative such as Adherence, Weight management, and Diabetes
Collaborate with Medical Directors and other interdepartmental staff to communicate pharmacy strategies and clinical programs or initiatives
Develops applicable desktop procedures for supporting PA applications
Reviews and resolves complaints made by members and providers regarding Prior Authorization, formulary or pharmacy services
Participates in support of the Pharmacy and Therapeutics Meeting to review and keep current on the drug formulary
Performs appropriate literature and clinical research
Knowledge of utilizing LexiComp, Facts and Comparisons, Micromedex, UptoDate, National guidelines, NCCN etc.
Collaborate to create clear communication to members and/or providers on prior authorization determinations
Works in partnership with pharmacy staff to assist in the implementation of utilization management programs
Works in collaboration with Program Manager to help with workflows and operational efficiencies
Evaluate opportunities for operational or process improvements
Support and manage other related health plan operations
Work adhering to US regulatory and Quality System requirements (21 CFR 820, etc.)
This position assumes and performs other duties as assigned.