at Navitus Health Services in Montpelier, Vermont, United States
Job Description
Overview
Due to growth, we are adding a Pharmacist I, Clinical Prior Authorization to our team!
The Pharmacist I, Clinical Prior Authorization will be responsible for: performing Prior Authorizations; perform duties related to Drug Utilization Review including concurrent, retrospective, and prospective components; and support Customer Care with clinical calls requiring pharmacist intervention. The Pharmacist I, Clinical Prior Authorization 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.
Is this you? Find out more below!
Responsibilities
How do I make an impact on my team?
- 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
- Provide input to clinical content of new programs and for maintenance of existing programs
- Complete all annual URAC training requirements
- 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
- May review health care survey data for Medicare Part D qualified participants and/or perform phone consultations with Med-D enrollees; aid in documentation of calls; designate enrollees for repeat interaction
- Other duties as assigned
Qualifications
What our team expects from you?
- A minimum of a bachelor’s degree in Pharmacy or Pharm D. Current, unrestricted licensure as a Registered Pharmacist in the state of residence, or the ability to gain reciprocity within 4 months, may be required based on state of residence laws or client contracts. Other State Pharmacy Licenses may be required as business need dictates. Must continually maintain education credits to maintain active licensure.
- Two years’ work experience in a clinical setting, or clinical or managed care pharmacy practice residency preferred
- 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 profic
Equal employment opportunity, including veterans and individuals with disabilities.PI288227433
