Clinical Pharmacy Specialist (Remote)- Prior Authorization Team

UPMC Senior Communities; Pittsburgh (Allegheny County); Remote; USD 95,000 - 130,000; Full time

Job summary

UPMC Health Plan is seeking a full-time Clinical Pharmacy Specialist to support the Prior Authorization Team within Pharmacy Services. This is a work-from-home daytime role (8:00 a.m.–5:00 p.m. EST) and requires PA licensure or eligibility for licensure.

The clinical pharmacist will review utilization management requests and participate in appeals while ensuring compliance with NCQA and CMS standards. Responsibilities include clinical review of prior authorization, step therapy, and quantity

Qualifications

• Bachelor of Science Degree in Pharmacy and/or Doctor of Pharmacy from an accredited U.S. School of Pharmacy.
• Experience in pharmacy benefit management, insurance, managed care preferred.
• Effective communication skills, both written and oral.
• Strong analytical ability and organizational skills.
• Computer literacy for pharmacy programming, word processing, data management.

Responsibilities

• Perform clinical review of Prior Authorization, Step Therapy, Quantity Limit and other utilization management requests per quality and time standards.
• Critically review utilization management requests against standard clinical criteria and policies.
• Participate in a clinical call queue to answer inquiries from internal and external stakeholders.
• Participate in the pharmacy appeals process and represent in fair hearings when needed.
• Contribute to other operational initiatives as assigned.
• Foster and maintain collaborative relationships with customers.
• Work independently in a virtual team setup with confidentiality.
• Demonstrate drug information skills for complex reviews.
• Understand DHS, CMS, PID, NCQA requirements relevant to clinical operations.
• Attend meetings, committees, and work groups; mentor students/residents if applicable.

Skills

Pharmacy degree

Strong communication

Analytical skills

Organizational skills

Computer literacy

Education

Pharm.D/Bachelor of Science in Pharmacy

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.

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).

Qualifications:

• 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