The Clinical Prior Authorization Pharmacist will be responsible for performing Prior Authorizations. They perform duties related to Drug Utilization Review including concurrent, retrospective, and prospective components; and support Customer Care with clinical calls requiring pharmacist intervention. The Clinical Prior Authorization Pharmacist is also responsible for interfacing with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries' benefits and therapeutic interventions, and reviewing/evaluating the health surveys and utilization data for program management and development. The Clinical Prior Authorization Pharmacist will coordinate with Clinical Account Executives and Program Managers to enhance their support and understanding of related Pharmacy Benefit Management (PBM) programs. Additionally, the Clinical Prior Authorization Pharmacist will develop and maintain appropriate clinical, evidence-based documentation that supports PBM programs.
Minimum two years' clinical experience, or clinical or managed care pharmacy practice residency and
1 year clinical experience. Knowledge of PBM industry, formulary management, pharmacy claims and managed care principles and practices desired. Exceptional clinical skills and ability to apply sound clinical judgment to a variety of situations is necessary.
Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline, Internet) preferred.
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 in order to assure projects are clinically, editorially, and systems accurate and can be operationalized.
Proficiency in MS Word, Excel, Power Point including tables, charts and figures preferred Responsibilities:
Responsible for 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 be 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
Complete all annual URAC training requirements
Responsible for participating in core teams working on new program/ product development.
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
Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee
Assists Customer Care, Client Services and other internal customers in responding to and resolving pharmacy-related inquiries from members, clients, providers, or pharmacies Preferred Qualifications:
Previous successful work at home experience
About the Company
BroadPath provides specialized business, compliance, and technology services to healthcare payers and providers in commercial and government sectors.
We focus solely on healthcare, so our team understands our clients' issues in a way few others can. And since we work with the country's top healthcare organizations, we have unique insight into the industry's best practices and of the dynamics and regulations affecting operations and outcomes.
Employment Type: Permanent
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