Pharmacy Prior Authorization & Clinical Review Specialist

UPMC; Bridgeville (Allegheny County); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Benefits package

Total rewards package

Job summary

UPMC Rx Partners is seeking a full-time Pharmacy Clinical Review Specialist to join our team. You will oversee administrative and system processes for pharmacy prior authorizations and conduct first-line clinical reviews to ensure payment for Community Provider Services and customers.

You will collaborate with clinicians to support medical documentation in line with formulary guidelines and participate in quality reviews of requested prior authorizations.

Qualifications

• Experience with pharmacy prior authorizations and clinical review.
• Familiarity with formulary guidelines and regulatory requirements.
• Ability to collaborate with clinicians to obtain medical documentation.

Responsibilities

• Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero.
• Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.
• Process requests and inquiries in accordance with all governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards.
• Perform peer reviews of prior authorization requests.
• Maintain or exceed designated quality and production standards.
• Develop and maintain the pre-logic and clinical criteria in support of the prior authorization determination process.
• Interface with other departments and identify medical documentation in support of prior authorization requests.
• Participates in the monthly billing process and assist with collection of delinquent accounts.
• Act as a conduit of information between the Pharmacy, operations and clinical and the facility staff.
• Report and respond to escalate issues and concerns in a within twenty-four hours.
• Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business.

Job description

UPMC Rx Partners is seeking a full-time Pharmacy Clinical Review Specialist to join our team. You will oversee administrative and system processes for pharmacy prior authorizations and conduct first-line clinical reviews to ensure payment for Community Provider Services and customers.

You will collaborate with clinicians to support medical documentation in line with formulary guidelines and participate in quality reviews of requested prior authorizations.