Clinical UM Pharmacist

HealthFirst; Las Vegas (NV); On-site; USD 103,000 - 149,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

401k contributions

Incentive programs

Job summary

HealthFirst seeks a Clinical UM Pharmacist to review prior authorization requests, develop clinical criteria, and ensure policy compliance with CMS and NYSDOH. You will collaborate with physicians and Medical Directors to discuss clinical rationale for decisions.

The role requires a NY-licensed pharmacist with at least 1 year of prior authorization experience, strong writing and communication skills, and a solid pharmacotherapy knowledge base. Knowledge of billing practices is a plus.

Qualifications

• Pharmacy degree from an accredited school; NY pharmacist license in good standing.
• Minimum 1 year experience conducting prior authorization reviews.
• Strong clinical knowledge of pharmaceuticals and disease states for POA reviews.
• Strong clinical writing and verbal skills; ability to document clearly.

Responsibilities

• Monitor and review prior authorization requests for medications.
• Calculate billable units based on dosing, indication, weight, BMI, and other clinical factors.
• Develop clinical criteria and medical policies for medication reviews.
• Ensure criteria compliance with CMS and NYSDOH regulations.
• Research drug information to support POA reviews.
• Perform drug utilization reviews (DUR) for medical benefit medications.
• Ensure timely POA reviews per CMS/NYSDOH timelines.
• Collaborate with cross-functional teams on Utilization Management reviews.
• Review monthly reports and present trends and recommendations.

Skills

Clinical knowledge

Verbal & written communication

Critical thinking

Team collaboration

Prior authorization experience

Education

Pharmacy degree

New York Pharmacist license

PGY1 Managed Care Residency

Tools

CMS/NYSDOH regulations

Microsoft Office (Outlook, Word, PPT, Excel)

Job description

The Clinical UM Pharmacist is a dynamic position responsible for the review of prior authorizations for medications requested under the medical benefit. Additionally, the Clinical UM Pharmacist is responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly report for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine. The Clinical Pharmacist works directly with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions.

Duties & Responsibilities

• Monitor and review prior authorization requests for medications
• Calculate appropriate billable units based on dosing, indication, weight, BMI and other clinical considerations
• Develop clinical criteria and medical policies for the review of medications
• Ensure all clinical criteria is in compliance with Center of Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH)
• Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
• Perform and present drug utilization reviews (DUR) on medical benefit medications to assess clinical appropriateness, safety, and cost-effectiveness
• Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH
• Work across departments as needed to complete Utilization Management reviews
• Review monthly reports and present on trends, ideas for efficiency/innovation, and medical spend
• Ability to work well in a team environment and be a team player
• Additional duties as assigned or required

Minimum Qualifications

• Pharmacy degree from an accredited school of pharmacyRegistered Pharmacist in the state of New York with a license in good standing.
• Minimum of 1 year experience conducting prior authorization reviews
• Strong clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews
• Strong clinical writing and verbal skills
• Demonstrated critical thinking and problem-solving skills.
• Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits
• Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities

Preferred Qualifications

• PGY1 Managed Care Residency (optional)
• Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations.
• Ability to lead large and small working meetings
• PC Skills with Microsoft Outlook, Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables).

License or Certification

Licensed pharmacist in the state of NY in good standing.

Regulatory or Compliance activities

Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

Hiring Range*

Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430

All Other Locations (within approved locations): $88,700 - $131,920

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements).

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.