Pharmacist I, Clinical Prior Authorization

Navitus; Madison (WI); Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Health, dental and vision insurance

20 days paid time off

4 weeks paid parental leave

9 paid holidays

401K company match up to 5%

Adoption Assistance Program

Flexible Spending Account

Educational Assistance Plan and Member

Professional Membership assistance

Referral Bonus Program – up to $750

Job summary

Navitus Health Solutions seeks a Pharmacist I, Clinical Prior Authorization to perform prior authorizations, drug utilization reviews, and pharmacist‑level clinical calls. You will interface with physicians and pharmacists to support beneficiaries’ benefits and therapy decisions.

You will evaluate health surveys and utilization data, contribute to program management, and help advance formulary and clinical program content across Navitus’ services.

Qualifications

• Bachelor’s degree in Pharmacy or PharmD and active licensure in the resident state.
• Two years’ clinical or managed care pharmacy experience preferred.
• Knowledge of PBM industry, formulary management, and pharmacy claims.
• Ability to apply clinical judgment to diverse situations.
• Proficiency with electronic databases (Micromedex, Medline) and MS Office.

Responsibilities

• Support clinical programs like Health Management, Drug Utilization Review, Formulary development, and Prior Authorization.
• Review coverage determinations and participate in execution of denial and approval workflows.
• Monitor and improve the Coverage Determination process and related communications with prescribers.
• Contribute to clinical content for new and existing programs; complete URAC training requirements.
• Educate clients, members, and internal staff on daily clinical issues and program objectives.
• Support operational departments with PBM program implementation and daily member care activities.
• Provide clinical expertise related to formulary decisions by the Pharmacy and Therapeutics committee.
• Review Medicare Part D survey data or conduct phone consultations as needed.

Skills

Clinical decision making

PBM industry knowledge

Pharmacy licensure knowledge

Communication skills

MS Office (Word/Excel/PowerPoint)

Education

Pharmacy degree (PharmD/Bachelor of Pharmacy)

Tools

Micromedex

Medline

Job description

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 holidays
• 401K 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.