Clinical Utilization Management Pharmacist

wvumedicine; United States; Remote; USD 110,000 - 150,000; Full time

Job summary

PHH Peak Health Holdings is seeking a Clinical Utilization Management Pharmacist to perform drug utilization review for initial determinations and appeals for ASO clients, Medicare Advantage, and future lines of business.

You will collaborate with the Medical Director and formulary team on specialty reviews, identify utilization trends, and ensure timely, regulatory-compliant reviews across multiple lines of business.

Qualifications

• Current and unrestricted pharmacist license in state of residence.
• 3 years of clinical pharmacist experience.
• 2 years of managed care experience.

Responsibilities

• Make prior authorization and step-therapy determinations for DRR across all lines of business.
• Participate in the appeals process for drug reviews.
• Own the operational execution of the drug utilization review process.
• Serve as SME for utilization management related to drug reviews.

Skills

Clinical pharmacy

Regulatory knowledge

Communication

MS Office

Problem solving

Education

Pharmacist license

Tools

Microsoft Office

Job description

Reporting to the Manager of Clinical Pharmacy, the Clinical Utilization Management Pharmacist is primarily responsible for performing drug utilization review for initial determinations and/or appeals for our ASO clients, Medicare Advantage plan, and any future lines of business as well as collaborating as an integral member of the pharmacy team. The responsibilities of this position also include serving as a subject matter expert for pharmacy utilization management in addition to ensuring the timely execution of all drug reviews in compliance with accreditation and regulatory standards. In addition, the Clinical Utilization Management Pharmacist will work with our Medical Director and Clinical Formulary team to review any specialty medication requiring a specialty consult as defined by our formulary team and identify any utilization review trends and areas of improvement that need to be addressed.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• Must possess current and unrestricted license to practice pharmacy issued by state of residence.

EXPERIENCE:

• Three (3) years of experience as a pharmacist in a clinical setting.
• Two (2) years of managed care experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

• Specific knowledge of CMS regulations, HIPAA and regulatory environment.

CORE DUTIES AND RESPONSIBILITIES:

• Make prior authorization and step therapy determinations for drug utilization reviews based upon available clinical evidence and supporting documentation for all lines of business.
• Participate in the appeals process for drug reviews for all lines of business.
• Own the operational execution of the drug utilization review process.
• Serve as an inter-departmental subject matter expert for utilization management as it relates to drug reviews.
• Work with the Manager of Clinical Pharmacy to ensure the timely execution of all drug reviews in compliance with accreditation and regulatory standards
• Work with the Manager of Clinical Pharmacy and Medical Directors to identify review trends and policy needs that need to be addressed.
• Work with the Manager of Clinical Pharmacy and Director of Clinical and Technical Integration to identify and upscale operational and technical issues as they relate to drug utilization management reviews that need to be addressed.
• Assist with internal and operational policy needs as they related to drug utilization management review.
• Work with the Manager of Clinical Pharmacy to resolve questions and disputes from our clients and participating providers regarding drug review determinations.
• Work with Medical Directors and formulary team to review and make recommendations on specialty drugs requiring a specialty consult as defined by our organization.
• Assist in monthly analysis of claims data to assess effectiveness of current formulary and utilization management strategies.
• Serve as a clinical pharmacy preceptor for residents and rotational pharmacy students as needed.
• Assist in creation of training materials for utilization management operational processes as needed.
• Assist in creation of clinical development tools for education as it relates to utilization review decision making as needed.

PHYSICAL REQUIREMENTS:

• Ability to stand and walk short distances for eight or more hours.
• Frequent bending, stooping or stretching.
• Ability to lift 30 pounds and push 50 pounds.

WORKING ENVIRONMENT:

• Standard office environment.
• Some travel may be required to offsite meetings.

SKILLS AND ABILITIES:

• Ability to work under stressful working conditions.
• Ability to handle and maintain confidential information.
• Ability to work cooperatively as a team member with articulate communication and presentation skills.
• Ability to work in a fast-paced and rapidly changing environment.
• Ability to work proactively and independently to research and resolve issues.
• Extensive working knowledge of Microsoft Office applications (Excel and Access).

Additional Job Description:

Scheduled Weekly Hours: 40

Shift:

Exempt/Non-Exempt: United States of America (Exempt)

Company: PHH Peak Health Holdings

Cost Center: 2405 PHH Medication Management