The Clinical Review Specialist will oversee administrative and system processes that relate to pharmacy prior authorizations. Manage the first line clinical review of prior authorization requests on behalf of physicians and UPMC Health Plan members. Collaborate with clinicians regarding supporting medical documentation in accordance with formulary guidelines. Manage the quality review of requested prior authorizations. This is a full-time position working Monday through Friday 11:30am-8:00 pm, with a Saturday rotation monthly. Training schedule will be 8:30am-5:00 pm Monday-Friday. Equipment will be provided. As this position is remote, please understand that we do have the ability to have staff report to and work from our primary location, US Steel Tower as well.
Responsibilities:
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Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero.
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Act as a conduit of information between the Pharmacy Service Representatives and the clinical staff
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Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business.
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Perform peer reviews of prior authorization requests.
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Maintain or exceed designated quality and production standards.
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Develop and maintain the pre-logic and clinical criteria in support of the prior authorization determination process.
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Interface with other departments and identify medical documentation in support of prior authorization requests.
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Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.
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Report and respond to escalate issues and concerns in a within twenty-four hours.
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Process requests and inquiries in accordance with all governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards.
