Clinical UM Pharmacist

Healthfirst., Inc.; New York (NY); On-site; USD 89,000 - 149,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Life insurance

401k contributions

Incentive programs

Job summary

Healthfirst, Inc. is seeking a Clinical UM Pharmacist to review prior authorizations for medical benefit medications and develop clinical criteria and medical policies.

You will work with physicians and medical directors, ensure CMS/NYSDOH compliance, and stay current with literature while presenting trends and cost implications. The role requires a NY license, a PharmD, and at least 1 year of prior authorization experience, with strong clinical and communication skills in a collaborative

Qualifications

• Pharmacy degree from an accredited school of pharmacy.
• Licensed pharmacist in New York in good standing.
• Minimum of 1 year experience conducting prior authorization reviews.
• Strong clinical knowledge to review medications and disease states.
• Strong writing and verbal communication skills.

Responsibilities

• Monitor and review prior authorization requests for medications.
• Calculate billable units based on dosing, indication, weight and other clinical factors.
• Develop clinical criteria and medical policies for medication reviews.
• Ensure criteria comply with CMS and NYSDOH.
• Review drug information to maintain knowledge for prior authorizations.
• Perform drug utilization reviews for medical benefit medications.
• Ensure reviews are conducted within CMS/NYSDOH timeframes.
• Collaborate with other departments for Utilization Management reviews.
• Review monthly reports and discuss trends and cost implications.
• Work effectively in a team environment.

Skills

Clinical knowledge of pharmaceuticals

Strong written and verbal skills

Critical thinking

Team player

Education

Pharmacy degree from an accredited school of pharmacy

Tools

Microsoft Outlook

Microsoft Word

Microsoft PowerPoint

Microsoft 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 pharmacy
• Registered 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. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [e-mail] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.

Know Your Rights

All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

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). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.