Pharmacist I, Clinical Prior Authorization

Navitus; Boston (MA); Remote; USD 120.000 - 160.000; Vollzeit

Benefits dieser Stelle

Health insurance

Dental insurance

Vision insurance

20 days paid time off

4 weeks parental leave

9 holidays

401K company match up to 5%

Adoption Assistance Program

Flexible Spending Account

Educational & Membership assistance

Referral Bonus Program – up to $750

Zusammenfassung

Navitus Health Solutions is hiring a Pharmacist I, Clinical Prior Authorization to join our expanding team in a remote-friendly role. You will perform prior authorizations, conduct drug utilization reviews, and support Customer Care with pharmacist interventions.

You will interface with physicians, pharmacists, and specialty providers regarding beneficiaries’ benefits and therapies. You will contribute to program management, review health survey data, and collaborate with internal staff to

Qualifikationen

• Bachelor’s degree in Pharmacy or PharmD with active pharmacist license; reciprocity may be required
• Two years clinical or managed care pharmacy experience or residency preferred
• Knowledge of PBM, formulary management, pharmacy claims and managed care principles
• Strong clinical skills and ability to apply sound clinical judgment
• Proficiency in drug literature and trial evaluation; familiarity with Micromedex and Medline
• Ability to translate clinical information for clinical systems and non-clinical audiences
• Problem-solving skills; ability to handle challenging situations and implement solutions
• Attention to detail to ensure accuracy across projects
• MS Word, Excel, and PowerPoint proficiency
• Participate in compliance program objectives
• Collaborate respectfully with colleagues

Aufgaben

• Support and input to clinical programs such as Health Management, DUR, formulary development, and PA programs
• Review requests in Coverage Determination processes and make determinations per criteria
• Monitor quality and efficiency of coverage determination and communications with prescribers
• Provide input to clinical content for new programs and maintenance of existing programs
• Complete annual URAC training requirements
• Educate clients, members, and internal staff on clinical issues and objectives
• Support operational departments on PBM program implementations
• Provide clinical expertise related to formulary decisions by the Pharmacy and Therapeutics committee
• Review Medicare Part D survey data and conduct phone consultations as needed
• Other duties as assigned

Kenntnisse

Clinical judgment

Communication

Problem solving

Attention to detail

Team collaboration

MS Word

MS Excel

PowerPoint

Ausbildung

Bachelor’s degree in Pharmacy

PharmD

Tools

Micromedex

Medline

MS Word

MS Excel

PowerPoint

Jobbeschreibung

Overview

Due to growth, we are adding a Pharmacist I, Clinical Prior Authorization to our team!

The Pharmacist I, Clinical Prior Authorization will be responsible for: performing Prior Authorizations; perform duties related to Drug Utilization Review including concurrent, retrospective, and prospective components; and support Customer Care with clinical calls requiring pharmacist intervention. The Pharmacist I, Clinical Prior Authorization is also responsible for interfacing with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries’ benefits and therapeutic interventions, and reviewing/evaluating the health surveys and utilization data for program management and development.

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 Prior Authorization 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
• Participate in the Coverage Determination (Certification, Prior Authorization, Medical Exception, Exception to Coverage, etc.) process be reviewing all requests which are not clearly approvable based on specified criteria (algorithms), making all coverage denial determinations, and identifying themselves by first name, title, and responsibility at Navitus in relation to drug utilization management program administration
• Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers
• Provide input to clinical content of new programs and for maintenance of existing programs
• Complete all annual URAC training requirements
• Facilitation of communication and education to clients, members, and internal staff regarding clinical daily issues and objectives
• Provide support to operational departments on the implementation of various PBM programs and daily functioning in support of member/patient quality of care
• Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee
• May review health care survey data for Medicare Part D qualified participants and/or perform phone consultations with Med-D enrollees; aid in documentation of calls; designate enrollees for repeat interaction
• 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 a Registered Pharmacist in the state of residence, or the ability to gain reciprocity within 4 months, may be required based on state of residence laws or client contracts. Other State Pharmacy Licenses may be required as business need dictates. Must continually maintain education credits to maintain active licensure.
• Two years’ work experience in a clinical setting, or clinical or managed care pharmacy practice residency preferred
• Knowledge of PBM industry, formulary management, pharmacy claims and managed care principles and practices desired
• Exceptional clinical skills and ability to apply sound clinical judgment to a variety of situations is necessary
• Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline, Internet) 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
• Requires attention to details to assure projects are clinically, editorially, and systems accurate and can be operationalized
• Proficiency in MS Word, Excel, 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 holidays401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!

#LI-Remote

Navitus Health Solutions is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, creed, sex, pregnancy, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by law.

Equal employment opportunity, including veterans and individuals with disabilities.

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