Clinical Pharmacist, Utilization Management

CDPHP in; City of Rochester (NY); Hybrid; USD 110,000 - 198,000; Full time

Job summary

CDPHP is seeking a Clinical Pharmacist in Utilization Management to oversee drug reviews, ensure safety and cost-effectiveness across Medicare, Commercial and Medicaid lines. You will work with providers, med directors, and internal teams to manage approvals, documentation, and case discussions.

The role emphasizes data accuracy, policy adherence, and mentoring junior staff, with potential for remote work on a case-by-case basis. NYS licensure and strong UM experience are required.

Qualifications

• Current NYS pharmacist license required.
• PharmD degree or Bachelor of Pharmacy required.
• Managed care / utilization management experience preferred.
• Experience in healthcare with data analysis or benefit interpretation preferred.
• Strong customer service orientation and communication skills.
• Proficient with Microsoft Word and Excel.

Responsibilities

• Conducts drug prior authorization, exception and medical necessity reviews.
• Collaborates with providers and internal staff to determine approval criteria.
• Performs first-line appeal and grievance reviews for medical and pharmacy drugs.
• Documents findings for medical director review and potential final determination.
• Provides drug information support to medical directors during clinical calls with prescribers.
• Maintains policies and contributes to training and audits as needed.

Skills

NYS pharmacist license

PharmD or BPharm

Managed care experience

Utilization management

Customer service

Microsoft Word/Excel

Education

Pharm.D.

Bachelor of Pharmacy

Tools

Microsoft Word

Excel

Job description

Clinical Pharmacist, Utilization Management (Finance)

Job Description

Summary

This position is responsible for and participates in a wide range of provider, patient, and employer initiatives and programs. The pharmacist supports all of our lines of business which include Medicare, Commercial, Exchange (Marketplace) and Medicaid. The focus of the UM Pharmacist is to manage the quality, appropriateness, safety and cost of medications for our members through the medical management of drugs across our pharmacy and medical benefits.

Essential Accountabilities

Level I

• Conducts drug prior authorization, exception and medical necessity reviews.
• Works with requesting providers or internal staff to determine whether the submitted clinical information and patient presentation meet the criteria for approval according to the drug policy, formulary availability, and specific coverage criteria.
• Conducts first line appeal and grievance reviews for medical and pharmacy drugs in accordance with compliance standards.
• Conducts comprehensive reviews and documentation of findings for submission to the medical director for final determination, as required by law.
• Provides comprehensive support directly to providers and pharmacies, as needed, to expedite the treatment of our members.
• Communicates effectively with our community providers for case discussions on clinical call backs, providing next step options based upon line of business analysis and level of reviews already completed.
• Provides drug information support to our medical directors during clinical calls with prescribers.
• Presents quarterly CAU review and analysis to the clinical team and compliance department.
• Participates in monthly case consistency meetings in collaboration with different business areas.
• Contributes to the maintenance and addition of relevant clinical information for the UM team's SharePoint site.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Maintains assigned policies (such as infertility, compounding, and off label reviews) keeping up with current clinical guidance and company strategy.
• Provides guidance, instruction and mentoring of pharmacy and other health care students involved in experiential rotations in the department.
• Takes lead role in audits, as necessary.
• Facilitates the onboarding and training of new hire pharmacists.
• Collaborates with Decision Criteria Coordinator to maintain and update decision criteria and denial language.
• Research subrogation questions and determine whether retroactive payment would be appropriate.

Level III (in addition to Level II Accountabilities)

• Identify and troubleshoot issues arising during use of care management tools.
• Guides level I/II teammates on clinical decision-making and UM process insight to resolve day-to-day issues and ensure the team's work is compliant, consistent, and of high quality.
• Revises and organizes key documents used by the UM staff to support case consistency.
• Conducts monthly quality assurance review for pharmacy reviews and identifies issues and cases for coaching and process changes.
• Presents on meetings to share information and processes with fellow team members.
• Participates in internal policy discussions with supervisors to ensure consistency.
• Ensure that affiliated team members receive necessary support.
• Take lead role in audits, as necessary.
• Participates in cross-functional company-wide workgroups.

Minimum Qualifications

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels

• Unrestricted and current NYS Licensed Pharmacist
• Pharm.D. In lieu of a Pharm.D., a Bachelors in Pharmacy is required.
• Managed care experience is strongly preferred, especially experience in utilization management. In lieu of managed care experience, proven record of successful experience in a high-volume retail or hospital pharmacy is accepted.
• Experience in an organized health care setting or in a practice environment with direct physician interaction, data analysis and/or benefit interpretation process experience is strongly preferred.
• Must possess strong customer service orientation and the ability to interface effectively with internal and external customers.
• Fundamental knowledge of drug information process/references and ability to conduct drug and disease information research required.
• Able to serve as a knowledgeable liaison to internal and external organizations, to foster positive relationships with our vendor/partners, and to appropriately advocate for the corporation.
• Strong computer skills. Proficient knowledge of Microsoft Word and Excel.

Level II (in addition to Level I Qualifications)

• A minimum of two years' experience in a managed care setting, specifically in utilization management.
• Experience and skillset in a therapeutic or pharmacy management area that is critical to the Health Plan's strategic program.

Level III (in addition to Level II Qualifications)

• A minimum of five years' experience in in a managed care setting, specifically in utilization management.
• Attained sufficient proficiency, skills and expertise to manage and be accountable for a specific area of business, such as specialty drugs, Medicare drug, rebate management, audit functions, etc.
• Demonstrate exceptional understanding of process and procedure utilizing the care management tools.
• Consistently demonstrates an in depth understanding of utilization management best practices, DLPs and guidance.

Physical Requirements

• Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.
• Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
• Ability to work in a home office for continuous periods of time for business continuity.
• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
• Ability to hear, understand, and speak clearly while using a phone, with or without a headset.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s)

E9: $110,093 - $198,168

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.