Pharmacist, Clinical Grievance and Appeals

Navitus Health Solutions, LLC; United States; Remote; USD 98,000 - 123,000; Full time

Job summary

An established industry player is seeking a Clinical Grievance and Appeals Pharmacist to enhance their Grievance and Appeals department. In this pivotal role, you will be responsible for performing appeals, conducting quality reviews, and interfacing with healthcare professionals to ensure effective therapeutic interventions. This position offers a unique opportunity to contribute to the development of cost-effective pharmacy benefit management programs while working in a supportive and diverse environment. If you have a passion for improving healthcare outcomes and possess strong clinical expertise, this role is an exciting opportunity to make a meaningful impact.

Benefits

Health insurance

Dental insurance

Vision insurance

20 days paid time off

4 weeks paid parental leave

9 paid holidays

401K company match

Adoption Assistance Program

Flexible Spending Account

Qualifications

• Bachelor’s degree in Pharmacy or Pharm D required.
• Minimum two years of clinical experience preferred.

Responsibilities

• Support clinical programs and perform quality reviews.
• Monitor Appeals and Grievance processes for efficiency.
• Provide clinical expertise related to formulary decisions.

Skills

Problem-solving skills

Attention to detail

Clinical reasoning

Communication skills

Education

Bachelor’s degree in Pharmacy

Pharm D

Tools

MS Word

MS Excel

MS PowerPoint

Micromedex

Medline

Job description

Company

Navitus

About Us

Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.

Pay Range

USD $98,384.00 - USD $122,980.00 /Yr.

Work Schedule Description

M-F 8am-5pm, CST; rotating weekends

Remote Work Notification

ATTENTION: Navitus is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

Overview

Due to growth, we are adding a Grievance and Appeals Pharmacist to our Grievance and Appeals department! The Clinical Grievance and Appeals Pharmacist will be responsible for performing Appeals and Redeterminations, Grievance Quality of Care reviews, perform duties related to Drug Utilization Review including concurrent, retrospective, and prospective components, and serve as a liaison and clinical support to the Grievance and Appeals staff for clinical calls requiring pharmacist intervention. The Clinical Grievance and Appeals Pharmacist is also responsible for interfacing with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries’ benefits and therapeutic interventions. Additional responsibilities include reviewing/evaluating the health surveys and utilizing data for program management and development. The Clinical Grievance and Appeals Pharmacist will coordinate with Clinical Account Executives and Program Managers to enhance their support and understanding of related Pharmacy Benefit Management (PBM) programs. Additionally, the Clinical Grievance and Appeals Pharmacist will develop and maintain appropriate clinical, evidence-based documentation that supports PBM programs. The primary functions involve ensuring that Navitus can provide clinically sound programs and medications in the most cost-effective manner and utilize technology to implement on-line PBM programs.

Is this you? Find out more below!

Responsibilities

How do I make an impact on my team?

• Responsible for support and input to clinical programs such as Health Management, Drug Utilization Review, Formulary development, and clinical programs to encourage appropriate, high-quality, cost-effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place.
• Perform quality reviews of: Prior Authorization forms, denial Language, PA Accel.
• Continually monitor the quality and efficiency of the Appeals, Redetermination and Grievance process including coverage criteria, denial language, and communication with prescribers.
• Review Grievances, Appeals, Complaints, and Redeterminations following all CMS, state, client, and Navitus standards.
• Provide input to clinical content of new programs and for maintenance of existing programs.
• Participate in audits, on-site or remote audits, as a clinical subject matter expert.
• Responsible for supporting/providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee.
• Learn and understand the up and downstream processes related to grievances and appeals.
• Contribute to the management of grievance and appeal resources/materials.
• Other duties as assigned.

Qualifications

What our team expects from you?

• A minimum of a bachelor’s degree in Pharmacy or Pharm D.
• Current unrestricted licensure as an RPh in the State of the home office of the pharmacist, or the ability to gain reciprocity within 4 months of employment is required.
• Preferred experience is a minimum of two years of clinical experience, or clinical or managed care pharmacy practice residency.
• Knowledge of PBM industry, formulary management, utilization review, pharmacy claims and managed care principles and practices desired.
• Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline) preferred.
• Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences.
• Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution.
• Strong attention to detail to assure projects are clinically, editorially, and systems accurate and can be operationalized.
• Proficiency in MS Word, Excel, and Power Point including tables, charts and figures preferred.
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees.

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance.
• 20 days paid time off.
• 4 weeks paid parental leave.
• 9 paid holidays.
• 401K company match of up to 5% - No vesting requirement.
• Adoption Assistance Program.
• Flexible Spending Account.

#LI-Remote

Location

Remote

Country

US