Clinical Pharmacy Specialist (Remote)- Prior Authorization Team

Life in Pittsburgh; Pittsburgh (Allegheny County); Remote; USD 105,000 - 135,000; Full time

Job summary

UPMC Health Plan is hiring a full-time Clinical Pharmacy Specialist to support the Prior Authorization Team. This work-from-home role operates 8:00 a.m.–5:00 p.m. EST and requires PA licensure and current RPh registration.

The specialist will perform clinical reviews for prior authorizations and appeals, ensure compliance with NCQA and CMS standards, and collaborate with internal teams to optimize member care.

Qualifications

• Licensed pharmacist in PA or eligible for licensure by examination or reciprocity.
• BSPharm or Pharm.D. from an accredited U.S. school.
• Experience in pharmacy benefit management or managed care preferred.
• Strong communication, analytical, and organizational skills.
• Computer literacy for pharmacy programming and data management.

Responsibilities

• Perform clinical review of Prior Authorization, Step Therapy, Quantity Limit requests per clinical criteria and policies.
• Critically review utilization management requests for approval/denial.
• Participate in clinical call queue for inquiries related to exception process.
• Contribute to the pharmacy appeals process and committee representation at hearings.

Skills

Analytical ability

Communication skills

Organizational skills

Computer literacy

Education

Bachelor of Science in Pharmacy (BSPharm)

Doctor of Pharmacy (Pharm.D.)

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. This is a daylight position working between the hours of 8:00 a.m. - 5:00 p.m. EST. 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.

Must be legally authorized to work in the United States, without requiring, now or in the future, sponsorship for employment visa status. UPMC does not participate in STEM OPT.

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).

• Bachelor of Science Degree in Pharmacy, and/or Doctor of Pharmacy Degree (Pharm.D.) from an accredited U.S. School of Pharmacy.
• Experience in pharmacy benefit management, insurance, managed care preferred and be knowledgeable in therapeutic interventions and other cost containment programs.
• Effective communication skills, both written and oral.
• Must have strong analytical ability and organizational skills.
• Computer literacy for pharmacy programming, word processing, data management.
• Assessment of job related skills and competency will be reviewed annually via daily functioning, job-related documentation, department based competency programs, and continuing education activities.

Preferred Experience:
Experience with claims adjudication, therapeutic substitution interventions, dose optimization and other cost containment programs is preferred. Experience in pharmacy benefit management, insurance, managed care such as completion of a managed care residency or 1-3 years managed care experience is preferred but not required.
Licensure, Certifications, and Clearances:
Registration as a registered pharmacist (RPh), in the Commonwealth of Pennsylvania or eligibility for licensure by examination or reciprocity.Continuing Education requirements met each bi-annual cycle for re-licensure, as evident by obtaining a minimum of 30 hours of continuing education every 2 years in structured pharmaceutical education as necessary by the state board.

• Pharmacist
• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran