PBM Clinical Pharmacist

Valid8 Financial, Inc.; Las Vegas (NV); On-site; USD 110,000 - 150,000; Full time

Job summary

SlateRx is seeking a Clinical Pharmacist to review coverage determinations and appeals in alignment with company protocols. You will collaborate with a team to support efficient, accurate, timely, and privacy-conscious decision making.

Responsibilities include interpreting guidelines, obtaining information, communicating decisions to prescribers and members, handling inquiries, and advising on formulary alternatives as needed. A US Pharmacist license is required, with a Pharm.D.

Qualifications

• Pharmacist license in at least one US state.
• Pharmacy degree (B.Pharm or Pharm.D) required.
• Experience with prior authorization and PBM processes.
• Knowledge of state and federal pharmacy regulations.

Responsibilities

• Interpret guidelines and review coverage determinations and appeals.
• Obtain additional information as needed to make decisions.
• Communicate decisions to prescribers, members and health professionals.
• Handle calls and escalations regarding determinations.
• Advise on formulary alternatives when appropriate.
• Utilize clinical resources to support utilization reviews.

Skills

Clinical guidelines

Prior Authorization

PBM industry knowledge

Drug therapy discussion

Regulatory compliance

Team collaboration

Computer proficiency

Education

Bachelor of Pharmacy or Pharm.D.

Tools

PA system

Job description

Founded by industry pioneers, SlateRx provides simple and affordable pharmacy benefit programs to employer groups, unions, public sector groups, health systems, and other payers throughout the United States. As the industry’s only PBX TM , SlateRx is creating real value for plan sponsors on day one through purchasing scale and continued management via innovation and transparency. Our model is designed to improve an out-of-touch healthcare model to make pharmacy benefits simple and affordable for plan sponsors and members.

Job Overview:

The Clinical Pharmacist is responsible for reviewing clinical coverage determinations and appeals in accordance with the criteria, policies and practices of SlateRx, LLC. The Clinical Pharmacist works as part of the team to meet business unit objectives and expectations regarding efficiency, accuracy, timeliness, privacy maintenance and quality decision making.

Responsibilities:

As a Clinical Pharmacist, your key responsibilities will include:

• Interpret clinical guidelines and review coverage determination and appeal requests based on SlateRx protocols and criteria, and individual client requirements as applicable.
• Conduct outreach to obtain necessary additional information as needed.
• Ensure timely communication of request decisions to applicable parties, including prescribers, members, and other healthcare professionals as applicable.
• Handle inbound phone calls and escalations from physicians or members regarding coverage determinations.
• Communicate with PA technicians and/or physicians regarding use of medications and advise of appropriate formulary alternatives when appropriate.
• Utilize multiple systems and other clinical resources to make proper decisions in utilization reviews.
• Act as a resource for drug information for staff and clients.
• Create clinical criteria protocol decision trees in the PA automated system.
• Create denial explanations and appropriate authorizations as templates in the PA system.
• Clearly document the reason for the decision in the case file.
• Ensure denial explanations are written in member friendly language, include the reason for denial, and are specific to the reviewed request.
• Identify and recommend improvements to senior leaders regarding training curriculum and clinical operations.
• Performs miscellaneous job-related duties as assigned.

Qualifications:

To excel in this role, you should possess the following qualifications:

• Knowledge in the healthcare, insurance or PBM industry.
• Experience working in a Prior Authorization unit.
• Knowledge of pharmacy benefit management, CDAG operational processes, and benefit plan design.
• Pharmaceutical and medical knowledge necessary to effectively discuss drug therapy issues with physicians and pharmacists.
• Working knowledge of applicable state and federal pharmacy regulations.
• Computer and typing proficiency.
• Ability to adapt to a dynamic and fast-paced environment.
• Ability to work with peers in a team effort.
• A well-organized and self-directed individual who is able to work with minimal amount of supervision.
• Capability to efficiently complete tasks in a demanding environment.

Education:

Bachelor of Pharmacy Degree or Pharm.D. required.

License Requirement:

Current, valid and unrestricted Pharmacist License in at least one state of the United States required.