Utilization Management Pharmacist

BlueCross BlueShield of South Carolina•Columbia, SC

9d•Onsite

About The Position

This role is primarily responsible for developing, maintaining, and producing clinical decision-support logic within the prior authorization (PA) review platform, as well as ensuring the platform’s ongoing functionality and accuracy. The pharmacist may also contribute to the Pharmacy and Therapeutics (P&T) Committee by preparing and presenting therapeutic class reviews and drug monographs. Additionally, this position supports PA processing by applying evidence-based clinical guidelines and criteria to promote the appropriate use of medications.

Requirements

Bachelor's in a job related field
3 years of clinical experience to include 1 year of experience with management of patient drug therapies that includes conducting utilization management and/or medication therapy management reviews.
Strong clinical pharmacy knowledge.
Excellent communication (verbal and written), and interpersonal skills.
Ability to exercise good judgment with a capacity of communicating with a diverse range of individuals.
Ability to handle confidential or sensitive information with discretion.
Strong customer service skills.
Commitment to professionalism and to advance patient care.
Microsoft Office.
Active, unrestricted pharmacy licensure in SC or state of residence.

Nice To Haves

Any additional certifications in Medication Therapy Management, immunotherapy, oncology, hemophilia, multiple sclerosis, or specialty related disease states is helpful.
Utilization Management program experience preferred including working with prior authorization program platforms.
Managed Medicaid experience working with preferred drug lists and UM criteria application.
Knowledge and expertise with management of specialty drug therapies.

Responsibilities

Conducts utilization management prior authorization reviews and evaluates opportunities to improve health outcomes and derive optimal value from health care resources.
Analyzes and reviews prior authorization requests for compliance with clinical criteria and treatment care guidelines, potential patient safety problems, including drug interactions, suboptimal medication regimens, duplicate therapy and cost savings opportunities.
Formulates recommendations to optimize the patients’ medication regiment applying evidence based medicine and national treatment guidelines.
Informs prescribers of potential drug therapy problems and influences prescribing.
Engages with and establishes credibility with members and physicians as a trusted source of information.
Provides information and coordinates activities with other care and disease management programs and serves as a clinical pharmacy resource.
Contributes to the development of clinical rules and decision trees for evaluating the appropriateness of drug therapy.