Clinical Specialty Review Pharmacist

MedOne Pharmacy Benefit Solutions; Dubuque (IA); Remote; USD 130,000 - 170,000; Full time

Benefits offered by this job

Health Insurance

Dental Insurance

Vision Insurance

401(k) Match

Paid Time Off

Professional Growth

Collaborative Culture

Job summary

MedOne Pharmacy Benefit Solutions is seeking a Clinical Specialty Review Pharmacist to evaluate clinical criteria and render coverage determinations for complex specialty therapies such as oncology and autoimmune diseases.

The role includes outbound consultations with physicians and patients, literature reviews to support decisions, and rigorous documentation in all cases, while aligning with medical necessity and benefit guidelines.

Qualifications

• Experience in managed care, specialty pharmacy, clinical review, utilization management, or prior authorization operations.
• Proficient in MS Office; familiarity with clinical resources (Micromedex, Lexicomp, Clinical Pharmacology).
• Ability to translate clinical information for clinical and non-clinical audiences.

Responsibilities

• Evaluate and interpret clinical guideline criteria to render coverage determinations for specialty medications.
• Perform outbound clinical consultation calls with physicians, providers, and patients regarding coverage questions.
• Conduct literature evaluation to support decisions beyond guidelines.
• Document thoroughly in prior authorization and appeal cases.

Skills

Clinical review

Utilization management

Prior authorization

Communication skills

Time management

Independent work

Microsoft Office

Microsoft Dynamics

Tools

Micromedex

Lexicomp

Clinical Pharmacology

Microsoft Dynamics

Job description

The Clinical Specialty Review Pharmacist role provides the unique opportunity to apply clinical expertise and high-level decision-making for complex specialty therapy prior authorization and appeals review (i.e. oncology, autoimmune, rare diseases, bleeding disorders, etc.), with additional opportunities to provide clinical consultation, evidence evaluation, and cross-functional support.

About MedOne:

MedOne is a full-service pharmacy benefit manager (PBM), serving clients and members nationwide. With a fully transparent, pass-through model, MedOne helps people conveniently access the most appropriate prescriptions at the most affordable price.

What You Will Do at MedOne:

Evaluate, review and interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering coverage determinations (approvals, part approvals, denials) with a focus on specialty medications

Perform outbound clinical consultation calls with physicians, healthcare providers, and patients, as requested and scheduled, to address questions regarding coverage determinations

Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations that are outside clinical guideline criteria

Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides

Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times

Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements

Engage in Pharmacy and Therapeutics Committee discussions/changes; and potential membership

Assist Member Advocate and Account Management teams with patient, provider and pharmacy requests requiring pharmacist intervention

Works to promote a team environment

Close collaboration with account management and clinical leadership

Assists and supports members of MedOne Pharmacy Benefit Solutions

Portrays the company in a positive image

Required to abide by all rules, regulations and policies of the employer

Other duties as assigned

What you will bring to MedOne:

Preferred 2-5+ years of experience in managed care, specialty pharmacy, clinical review, utilization management, or prior authorization operations

Proficient in Microsoft Office Suite and experience using clinical resources (Micromedex, Lexicomp, Clinical Pharmacology)

Ability to translate clinical information into a manner appropriate for both clinical and non-clinical audiences

High degree of emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution

Detail-oriented with a high degree of accuracy

Strong interpersonal, written, and verbal communication skills

Ability to work independently and manage time effectively

Must have a designated workplace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations (for remote employees)

Familiarity with data entry software or CRM systems (Microsoft Dynamics) is preferred

Must be able to type at a minimum of 40-50 words per minute

Must be able to work independently, meets deadlines, establish priorities, and be flexible

Must be able to stand/sit for long periods of time within limited space

Must be able to lift up to 25 pounds

Must be able to work cooperatively with MedOne staff

Excellent customer service and teamwork skills

Why Join MedOne?

Competitive salary and bonuses that reward your performance

Comprehensive health, dental, and vision insurance

401(k) with company match to secure your future

Generous paid time off and holidays

Opportunities for professional growth and development

A vibrant and collaborative work culture