This position will be the expert of the team on clinical issues in conjunction with the Director of Pharmacy and other staff pharmacists. This position will be responsible for working in a collaborative culture focused on designing, implementing, maintaining and measuring pharmacy-related utilization management programs. This includes but is not limited to development of work flows, criteria development and ensuring that URAC accreditation is maintained. Additionally, supporting Medicare Advantage processes, outreach, and tasks that require clinical discussion and presentation.
Candidates applying to this position may be hybrid or remote and can live in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas. What you'll do:- Create and Maintain Clinical Criteria for applicable Utilization Management (UM) programs: Develop and maintain clinical criteria (access to Prime standard and BCBSNE specific versions); Develop and maintain criteria process flows; Develop and maintain physician fax forms and other modes of communication; Utilize predictive modeling tool to intervene with high-risk members for identified disease states; Provide clinical updates as necessary to internal staff and physician reviewers; Performs highly complex research, analysis and develops recommendations for UM programs & plan design changes.
- Responsible for Operational workflows and Completion of UM reviews: Clinical oversight of first level review process; Clinical review of utilization management reviews; Perform clinical support for Pharmacy Technician and other staff; Utilize reporting tools to create efficiencies by reviewing medical and pharmacy claims data; Support physician reviewers with information required to efficiently review non-approvable claims; Develop Decision Tree review process when applicable.
- Maintain URAC accreditation: Work with internal staff to ensure that URAC accreditation is maintained; The pharmacist will work within their scope of licensure and unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting drug utilization review. The clinical pharmacists may not conduct peer clinical review non-certifications for drug utilization management, if prohibited by state utilization management laws. The clinical pharmacists may not conduct peer clinical review non-certifications for drug utilization management if the requesting party specifically requests a clinical peer. Measure quality assurance reporting, turnaround time for urgent and non-urgent reviews and quantitative assessment of UM reviews by program.
- Support Medicare Advantage processes, outreach, presentations, and tasks that require clinical direction and support. This includes, but not limited to, clinical presentations to internal and external stakeholders, providers, provider offices, and other customers.
To be considered for this position, you must have:- Doctor of Pharmacy required from Accredited US College of Pharmacy.
- An active, current, and unrestricted license or certification to practice pharmacy in Nebraska within 6 months of hire.
The strongest candidates for this position will also possess:- Experience with PBM operations, Medicare Advantage, and/or clinical program development and maintenance.
- Managed Care Pharmacy Residency or 3-4 years of experience in Managed Care Pharmacy industry.
