Clinical Pharmacy Specialist- Prior Authorization

UPMC; Pittsburgh (Allegheny County); Remote; USD 90,000 - 120,000; Full time

Job summary

UPMC Health Plan is seeking a full-time Clinical Pharmacy Specialist to support the Prior Authorization Team. This remote position requires a Pennsylvania pharmacist license and involves managing pharmacy utilization and member care through prior authorization processes. Candidates should demonstrate professionalism and commitment to UPMC goals.

Qualifications

• Must be licensed in Pennsylvania or eligible for licensure.
• Experience in pharmacy utilization management is preferred.
• Ability to work independently and collaboratively in a virtual team.

Responsibilities

• Perform clinical review of Prior Authorization and pharmacy utilization requests.
• Critically review requests for approval/denial against clinical criteria.
• Participate in the pharmacy appeals process and operational initiatives.

Skills

Clinical pharmacy expertise

Drug information skills

Professionalism

Education

Registered pharmacist (RPh) in Pennsylvania

Job description

UPMC Health Plan is hiring a full-time Clinical Pharmacy Specialist to support the Prior Authorization Team within the Pharmacy Services department. This is a work-from-home position, working Eastern Standard time zone daylight hours Monday through Friday with rotating weekend responsibilities. Located anywhere in the United States but must be licensed in PA.

Registration as a registered pharmacist (RPh), in the Commonwealth of Pennsylvania or eligibility for licensure by examination or reciprocity is required.

The Clinical Pharmacy Specialist provides clinical pharmacy expertise to the development, implementation, and management of the pharmacy benefit.The clinical pharmacist assists in the management of pharmacy utilization and provides expertise in managing member care through the prior authorization and appeals process for medications. These services will be provided in compliance with state and federal regulations including NCQA and CMS standards while upholding the mission, policies and procedures of UPMC Health Plan and Pharmacy Department. Individual candidates should demonstrate professionalism and commitment to meet UPMC HP goals and objectives.

Responsibilities:

The Prior Authorization Pharmacist primary responsibilities include:

• Perform the clinical review of Prior Authorization, Step Therapy, Quantity Limit, and all other pharmacy utilization management requests in accordance with quality, timeliness, and efficiency standards.
• Critically review pharmacy utilization management requests for approval/denial against standard clinical criteria and regulatory approved policies.
• Participate in a clinical call queue to receive inquiries from internal and external stakeholders pertaining to the exception process while answering in a timely, accurate and professional manner.
• Participate in the pharmacy appeals process through the review of denied cases as well as serving as committee representation at fair hearings.
• Participate in and contribute to other operational initiatives on an as needed basis.

Additional responsibilities and attributes include:

• Foster and maintain collaborative relationships with internal and external customers.
• Perform job duties independently, reliably, efficiently, accurately, and professionally while supporting a virtual team concept.
• Demonstrate keen drug information skills to adequately research drugs and disease states pertaining to complex utilization management reviews or other ancillary responsibilities.
• Utilize a home office set-up that honors client and patient confidentiality.
• Maintain a foundational understanding of the requirements of the Pennsylvania Department of Human Services (DHS), Centers for Medicare & Medicaid Services (CMS), Pennsylvania Insurance Department (PID), and the National Committee for Quality Assurance (NCQA), as they relate to the compliance and regulatory requirements of clinical operational functions.
• Participate in meetings, committees, and work groups as assigned.
• Mentor students, residents, and other pharmacists (if applicable