Clinical UM Pharmacist: Prior Authorization Leader

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

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