Clinical Prior Authorization Pharmacist

Western Health Advantage; Sacramento (CA); On-site; USD 120,000 - 180,000; Full time

Job summary

Western Health Advantage is seeking a Clinical Pharmacist to perform the clinical review of medical and outpatient UM cases, issuing timely coverage determinations for drug prior authorizations, exceptions, and appeals. You will apply clinical guidelines and regulatory requirements to support decision making.

You will collaborate with network providers and staff, contribute to formulary development, monitor PBM P&T outputs, and provide recommendations for process improvements to department

Qualifications

• Pharmacist with clinical UM review experience.
• Ability to communicate with network providers and staff.
• Familiarity with NCQA, DMHC and Board of Pharmacy regulations.

Responsibilities

• Perform clinical review of UM cases and issue PA, exception and appeal determinations.
• Communicate rationale to network providers and staff.
• Contribute to formulary development and PBM P&T oversight.
• Ensure compliance with WHA policies and regulatory requirements.
• Provide process improvement recommendations to department leadership.

Skills

Clinical Review

Utilization Management

Prior Authorization

Communication

Formulary Development

Regulatory Compliance

PBM Knowledge

NDC Management

Job description

Clinical Pharmacists function in many areas within the pharmacy department. Clinical Pharmacists perform the clinical review of medical and outpatient pharmacy Utilization Management (UM) cases, using their clinical acumen and benefit information into consideration when issuing a decision. Clinical Pharmacists are charged with adhering to all regulations in their decision making, including NCQA, DMHC and Board of Pharmacy. Provide timely coverage determinations for drug prior authorizations (PA), exception requests, and appeals utilizing posted drug criteria, clinical guidelines, and creditable drug information resources. They need to communicate effectively with network providers and staff, discussing member prior authorizations and decision rationale.

Clinical Pharmacists are responsible for formulary development activities for multiple lines of business including participating in the Pharmacy Oversight Committee (POC) and collaborate to oversee the PBM’s P&T Committee criteria outputs. Review and provide clinical input on PBM formulary decisions, utilization management criteria, and therapeutic category updates as necessary. They provide clinical oversight for the accuracy of claims adjudication, as needed. Clinical Pharmacists manage new-to-market products, National Drug Codes (NDCs), and communication with the PBM’s Clinical Consultant. Clinical Pharmacists support the management and updates of the preferred drug list. Clinical Pharmacists monitor PBM P&T changes for compliance with WHA policies and regulatory requirements. Clinical Pharmacists also provide recommendations on process improvement to department leadership.

The Clinical Pharmacist will primarily support prior authorization (PA) operations, ensuring timely, compliant, and clinically sound coverage determinations.