Senior Clinical Advisor

Rxadvance Corporation; Southborough (MA); On-site; USD 125,000 - 160,000; Full time

Job summary

RxAdvance Corporation seeks a Senior Clinical Advisor in Southborough, MA to leverage pharmacy acumen and payer knowledge for PA reviews, policy development, and analytics within Pharmacy Operations. The role involves collaborating with pharmacists and technicians to support PA processes and quality programs.

The ideal candidate has PharmD, PBM experience, and strong analytical and communication skills, with a focus on regulatory compliance and patient outcomes.

Qualifications

• Doctor of Pharmacy (PharmD) degree from an ACPE accredited college is required.
• Managed Care or Clinical Residency program residency highly preferred.
• 3–5 years of recent experience as a senior/lead pharmacist preferably in a PBM or health plan setting.
• Experience with Medicare Part D highly preferred.
• Must have a regard for confidential data and adherence to corporate compliance policy.
• Expert knowledge of the principles and practices of pharmaceutical science, a working knowledge of managed care and policy development as well as working knowledge of state and federal controlled substances and related laws, rules, and regulations.
• Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology.
• Registered and in good standing with the Board of Registration in Pharmacy.

Responsibilities

• Works with leadership on special projects to unlock capacity and improve efficiency.
• Translates client product requirements into technical design specifications and data flow for development, coding, and configuration.
• Coordinates activities as part of Formulary Development and Maintenance and recommends performance improvements.
• Conducts and evaluates research for utilization management strategies.
• Performs clinical reviews of PA, Step Therapy, Quantity Limit, and other pharmacy utilization requests.
• Performs coverage determinations and appeals according to guidelines and regulations.
• Responds to PA guideline coding and rationale questions.
• Represents RxAdvance in client meetings and with external entities.
• Identifies opportunities for continuous quality and efficiency improvements.
• Provides support for audits and surveys.

Skills

Clinical review

Initiative/Judgment

Analytical skills

Communication skills

Self-motivation

Prioritization

Education

PharmD

Residency preferred

Tools

Micromedex

Lexicomp

Clinical Pharmacology

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Senior Clinical Advisor

Full Time Professional Southborough, MA, US

Salary Range: $125,000.00 To $160,000.00 Annually

Company Overview:

Join us in our mission to transform healthcare! nirvanaHealth (under RxAdvance Corp.) is committed to bringing the art of the possible to the payer and PBM industries. We invest in our employees at every stage of life. Success radiates across all levels of our organization, driven by competitive benefits and a strong focus on employee wellness, we aim to support all aspects of employee growth.

Characterized by curiosity, innovation, and an entrepreneurial mindset, nirvanaHealth is the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria – the first robotic process automation cloud platform designed for healthcare.

Under the leadership of our Chairman John Sculley, former Apple CEO, and our President & CEO Ravi Ika, nirvanaHealth endeavors to sizably reduce the $1 trillion in waste in healthcare administrative and medical costs. We are seeking self-determined players to join our team – folks who embrace the grind and hustle of a growing company, are collaborative and innovative, are life‑long learners and growers, and have an entrepreneurial and positive mindset.

Job Summary:

The Senior Clinical Advisor is responsible for utilizing pharmacy acumen, medication expertise, and healthcare payer knowledge related to drug‑related prior authorization requirements and medication guidelines to support PA operations (in completing PA reviews), PA technology and automation, consultation on evidence‑based guidelines and pharmacy policy, reporting and analytics, and quality management programs. The PBM Pharmacist will collaborate with a team of pharmacy technicians and pharmacists in Pharmacy Operations.

Job Responsibilities (but not limited to):

• Works with leadership on special projects such as, but not limited to, unlocking capacity and improving efficiency.
• Works with stakeholders to understand client’s product‑specific requirements and configuration needs and translate them into technical design specifications and data flow for development, coding, and configuration.
• Coordinates activities as part of the Formulary Development and Maintenance team and recommends measures to improve performance and efficiency.
• Conducts and evaluates research necessary for the development of utilization management strategies.
• Performs clinical reviews of PA, Step Therapy, Quantity Limit, and all other pharmacy utilization requests in accordance with quality, timeliness, and efficiency standards.
• Performs coverage determinations and appeals requests according to criteria guidelines and in compliance with all state and federal regulations, including Medicare and Medicaid.
• Researches and appropriately responds to PA guideline coding and rationale questions.
• Represents RxAdvance in client meetings as well as with external entities as needed.
• Identifies opportunities for continuous quality and efficiency improvements.
• Makes strategic recommendations including benefit design and formulary analysis, provision of clinical drug information, Pharmacy & Therapeutics support and participation, rational drug formulary positioning, online system edits and restrictions, ongoing clinical product evaluations, and client pharmacy benefit utilization and performance trends as required.
• Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical, financial, and operational effectiveness and quality.
• Provides support for internal and external audits and surveys.

Qualifications:

Education:

• Doctor of Pharmacy (PharmD) degree from an ACPE accredited college is required.
• Managed Care or Clinical Residency program residency highly preferred.

Professional Experience:

• 3 – 5 years of recent experience as a senior/lead pharmacist preferably in a PBM or health plan setting.
• Experience with Medicare Part D highly preferred.
• Must have a regard for confidential data and adherence to corporate compliance policy.
• Expert knowledge of the principles and practices of pharmaceutical science, a working knowledge of managed care and policy development as well as working knowledge of state and federal controlled substances and related laws, rules, and regulations.
• Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology.

Licenses/Certifications:

• Registered and in good standing with the Board of Registration in Pharmacy.

Specialized Skills:

• Strong clinical review competency.
• Requires a high degree of initiative and excellent judgment to make decisions regarding clinical pharmacy issues in an extremely complex and often politically charged environment.
• Requires excellent analytical skills necessary for program implementation, maintenance and enhancement and ability to analyze, assess and monitor physicians' prescribing trends and drug utilization patterns for clinical appropriateness and cost‑effectiveness with the Plan's operations and goals.
• Highly developed oral/written communication skills, self‑motivation, and ability to work independently with minimal supervision are necessary.
• Must be flexible and able to constantly review and reset priorities, often daily, and to handle multiple projects simultaneously.
• Must be able to appropriately identify emergency situations and follow through with the appropriate protocol.

Technical Skills:

• Strong PC skills; MS Word, Excel, Access, and Power Point.