Reporting to the Manager of Clinical Pharmacy, the Clinical Utilization Management Pharmacist is primarily responsible for performing drug utilization review for initial determinations and/or appeals for our ASO clients, Medicare Advantage plan, and any future lines of business as well as collaborating as an integral member of the pharmacy team. The responsibilities of this position also include serving as a subject matter expert for pharmacy utilization management in addition to ensuring the timely execution of all drug reviews in compliance with accreditation and regulatory standards. In addition, the Clinical Utilization Management Pharmacist will work with our Medical Director and Clinical Formulary team to review any specialty medication requiring a specialty consult as defined by our formulary team and identify any utilization review trends and areas of improvement that need to be addressed.
MINIMUM QUALIFICATIONS :
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Must possess current and unrestricted license to practice pharmacy issued by state of residence.
EXPERIENCE:
1. Three (3) years of experience as a pharmacist in a clinical setting.
2. Two (2) years of managed care experience.
PREFERRED QUALIFICATIONS :
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Specific knowledge of CMS regulations, HIPAA and regulatory environment.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Make prior authorization and step therapy determinations for drug utilization reviews based upon available clinical evidence and supporting documentation for all lines of business.
2. Participate in the appeals process for drug reviews for all lines of business.
3. Own the operational execution of the drug utilization review process.
4. Serve as an inter-departmental subject matter expert for utilization management as it relates to drug reviews.
5. Work with the Manager of Clinical Pharmacy to ensure the timely execution of all drug reviews in compliance with accreditation and regulatory standards
6. Work with the Manager of Clinical Pharmacy and Medical Directors to identify review trends and policy needs that need to be addressed.
7. Work with the Manager of Clinical Pharmacy and Director of Clinical and Technical Integration to identify and escalate operational and technical issues as they relate to drug utilization management reviews that need to be addressed.
8. Assist with internal and operational policy needs as they related to drug utilization management review.
9. Work with the Manager of Clinical Pharmacy to resolve questions and disputes from our clients and participating providers regarding drug review determinations.
10. Work with Medical Directors and formulary team to review and make recommendations on specialty drugs requiring a specialty consult as defined by our organization.
11. Assist in monthly analysis of claims data to assess effectiveness of current formulary and utilization management strategies.
12. Serve as a clinical pharmacy preceptor for residents and rotational pharmacy students as needed.
13. Assist in creation of training materials for utilization management operational processes as needed.
14. Assist in creation of clinical development tools for education as it relates to utilization review decision making as needed.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Ability to stand and walk short distances for eight or more hours.
2. Frequent bending, stooping or stretching.
3. Ability to lift 30 pounds and push 50 pounds.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment.
2. Some travel may be required to offsite meetings.
SKILLS AND ABILITIES:
1. Ability to work under stressful working conditions.
2. Ability to handle and maintain confidential information.
3. Ability to work cooperatively as a team member with articulate communication and presentation skills.
4. Ability to work in a fast-paced and rapidly changing environment.
5. Ability to work proactively and independently to research and resolve issues.
6. Extensive working knowledge of Microsoft Office applications (Excel and Access).
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Exempt/Non-Exempt:
United States of America (Exempt)
Company:
PHH Peak Health Holdings
Cost Center:
2405 PHH Medication Management
