Clinical UM Pharmacist, NY License Required

Healthfirst; New York (NY); Hybrid; USD 89,000 - 149,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Life insurance

401k contributions

Incentive and recognition programs

Job summary

Healthfirst is seeking a pharmacist in New York to monitor and review prior authorization requests for medications, ensuring alignment with CMS and NYSDOH guidelines. The role involves calculating billable units, developing clinical criteria, and performing drug utilization reviews to assess safety and cost-effectiveness.

The candidate should hold a Pharmacy degree and be licensed in New York, with at least 1 year of prior authorization experience.

Qualifications

• Strong clinical knowledge of pharmaceuticals and disease states to conduct prior authorization reviews.
• Excellent written and verbal communication skills for policy development and case presentations.
• Ability to interpret CMS and NYSDOH guidelines and apply them to reviews.

Responsibilities

• Monitor and review prior authorization requests for medications.
• Calculate billable units based on dosing, indication, weight, BMI and clinical considerations.
• Develop clinical criteria and medical policies for medication reviews.
• Ensure all criteria comply with CMS and NYSDOH.
• Perform and present drug utilization reviews for medical benefit medications.
• Ensure reviews are conducted within CMS/NYSDOH timeframes.
• Collaborate with other departments on Utilization Management reviews.
• Review monthly reports and present trends and ideas for efficiency.

Skills

Clinical knowledge

Critical thinking

Verbal communication

Education

Pharmacy degree

New York pharmacist license

Job description

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).

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.

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.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.