Clinical UM Pharmacist

Healthfirst; Texas; Sur place; USD 89 000 - 149 000; Plein temps

Avantages offerts par ce poste

Medical, dental and vision coverage

Life insurance

401k contributions

Résumé du poste

Healthfirst in New York is seeking a Clinical UM Pharmacist to review prior authorization requests for medications under the medical benefit and to develop clinical criteria and medical policies for provider-administered medications.

The role requires collaboration with prescribing physicians and Medical Directors, strong clinical writing, and up-to-date knowledge of CMS/NYSDOH guidelines to ensure timely reviews and evidence-based decisions.

Qualifications

• Pharmacist licensed in NY in good standing.
• Minimum of 1 year experience conducting prior authorization reviews.
• Strong clinical knowledge of pharmaceuticals and disease states.
• Strong clinical writing and verbal skills.
• Demonstrated critical thinking and problem-solving skills.
• Knowledge of specialty pharmaceuticals and medical billing practices.
• Passion for learning and growing skills in a dynamic environment.

Responsabilités

• 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 complies with CMS and NYSDOH requirements.
• Research drug information to support prior authorization decisions.
• Perform drug utilization reviews for medical benefit medications.

Connaissances

Pharmacist license NY

Prior authorization review

Clinical writing

Critical thinking

Team collaboration

Billing knowledge

Disease state knowledge

Learning mindset

Formation

Pharmacy degree

Outils

Microsoft Office

Description du poste

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

MinimumQualifications

• 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).

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.

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.

• 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.