Clinical Pharmacist

nirvanaHealth | RxAdvance; Southborough (MA); On-site; USD 90,000 - 120,000; Full time

Job summary

nirvanaHealth, operating under RxAdvance Corp., seeks a Clinical Advisor to apply pharmacy expertise and payer knowledge to PA reviews, policy, analytics, and quality programs. You will collaborate with pharmacy technicians and pharmacists in Pharmacy Operations to support PA processes.

Responsibilities include formulary development, data translation for design, and coordinating P&T activities to optimize clinical and operational outcomes.

Qualifications

• Bachelor’s degree in pharmacy or related field. ACPE accreditation preferred.
• PharmD degree preferred; managed care residency highly preferred.
• Experience in managed care or PBM settings is desirable and relevant.

Responsibilities

• Serve as SME in drug formularies and clinical programs.
• Translate client requirements into technical design and data flow for development and configuration.
• Coordinate Formulary Development and Maintenance activities to improve performance.
• Conduct utilization management research and develop criteria for new markets.
• Perform PA, Step Therapy, Quantity Limit reviews consistent with regulations.
• Handle coverage determinations and appeals per regulatory guidelines including Medicare/Medicaid.
• Interact with stakeholders to support PA processes and timely responses.
• Develop utilization criteria for market updates and provide evidence-based recommendations.
• Support FWA program oversight and report suspected fraud.

Skills

Pharmacy acumen

Payer knowledge

Clinical decision-making

Education

Bachelor’s degree in pharmacy

PharmD preferred

ACPE accreditation preferred

Tools

Micromedex

Lexicomp

Clinical Pharmacology

Job description

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.