Clinical Advisor

nirvanaHealth, LLC; Tampa (FL); On-site; USD 100,000 - 110,000; Full time

Job summary

nirvanaHealth, anRxAdvance Corp. portfolio, seeks a Clinical Advisor in Southborough, MA, to support drug-related prior authorization and payer guidelines.

The role collaborates with pharmacy technicians and pharmacists in Pharmacy Operations to optimize PA reviews, automation, and policy, leveraging evidence-based standards. The ideal candidate has pharmacy acumen, PA expertise, formulary experience, and familiarity with Medicare/Medicaid processes.

Qualifications

• Bachelor’s degree in pharmacy required.
• PharmD degree preferred.
• 1 year managed care experience preferred.

Responsibilities

• Serve as SME in formulary development and clinical programs.
• Coordinate PA operations, reviews, and automation.
• Conduct clinical reviews for PA, Step Therapy, and quantity limits.
• Prepare analytics and reports on PA utilization and outcomes.

Skills

Pharmacy acumen

PA knowledge

Formulary development

Clinical reviews

Medicare/Medicaid knowledge

Evidence-based guidelines

Education

Bachelor’s degree in pharmacy

PharmD preferred

Managed Care or Clinical Residency experience

Tools

Micromedex

Lexicomp

Clinical Pharmacology

Job description

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Clinical Advisor

Southborough, MA, US

30+ days ago Requisition ID: 1147

Salary Range: $100,000.00 To $110,000.00 Annually

Job Posting Title Clinical Advisor

Job Description

Company Overview:

Join us in our mission to transform healthcare! nirvanaHealth (under RxAdvance Corp.) is committed to bringing the art of the possible to the payer and PBM industries. We invest in our employees at every stage of life. Success radiates across all levels of our organization, driven by competitive benefits and a strong focus on employee wellness, we aim to support all aspects of employee growth.

Characterized by curiosity, innovation, and an entrepreneurial mindset, nirvanaHealth is the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria – the first robotic process automation cloud platform designed for healthcare.

Under the leadership of our Chairman John Sculley, former Apple CEO, and our President & CEO Ravi Ika, nirvanaHealth endeavors to sizably reduce the $1 trillion in waste in healthcare administrative and medical costs. We are seeking self-determined players to join our team – folks who embrace the grind and hustle of a growing company, are collaborative and innovative, are life‑long learners and growers, and have an entrepreneurial and positive mindset.

Job Summary:

The Clinical Advisor is responsible for utilizing pharmacy acumen, medication expertise, and healthcare payer knowledge related to drug‑related prior authorization requirements and medication guidelines to support PA operations (in completing PA reviews), PA technology and automation, consultation on evidence‑based guidelines and pharmacy policy, reporting and analytics, and quality management programs. The Clinical Advisor will collaborate with a team of pharmacy technicians and pharmacists in Pharmacy Operations

Job Responsibilities (but not limited to):

• Serves as a subject matter expert in the development and maintenance of drug formularies and clinical programs.
• Works with stakeholders to understand client’s product‑specific requirements and configuration needs and translate them into technical design specifications and data flow for development, coding, and configuration.
• Coordinates activities as part of the Formulary Development and Maintenance team and recommends measures to improve performance and efficiency.
• Manage operations of the Pharmacy & Therapeutics (P&T) Committee including scheduling drug class reviews, reviewing new branded agents, coordinating internal/external membership, documenting P&T minutes, and preparing and organizing P&T files.
• Conducts and evaluates research necessary for the development of utilization management strategies.
• Performs clinical reviews of PA, Step Therapy, Quantity Limit, and all other pharmacy utilization requests in accordance with quality, timeliness, and efficiency standards.
• Performs coverage determinations and appeals requests according to criteria guidelines and in compliance with all state and federal regulations, including Medicare and Medicaid
• Takes calls from internal and external stakeholders as it pertains to the PA process, answering in a timely, accurate and professional manner.
• Develops and implements clinical utilization criteria for new market entries and market updates utilizing evidence‑based medicine principles.
• Makes strategic recommendations including benefit design and formulary analysis, provision of clinical drug information, Pharmacy & Therapeutics support and participation, rational drug formulary positioning, online system edits and restrictions, ongoing clinical product evaluations, and client pharmacy benefit utilization and performance trends as required.
• Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical, financial, and operational effectiveness and quality.
• Supports Fraud, Waste and Abuse (FWA) program system oversight and communicates any suspected fraud discovered.

Education and/or Training:

• Bachelor’s degree in pharmacy or related fields required.
• Doctor of Pharmacy (PharmD) degree from an ACPE accredited college is preferred.
• Managed Care or Clinical Residency program residency highly preferred.

Professional Experience:

• At least 1 year of recent managed care experience in a PBM or health plan setting is preferred.
• Experience with Medicare Part D highly preferred.
• Expert knowledge of the principles and practices of pharmaceutical science, a working knowledge of managed care and policy development as well as working knowledge of state and federal controlled substances and related laws, rules, and regulations.
• Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology.

Licenses/Certifications:

• Registered and in good standing with the Board of Registration in Pharmacy.