Job Description
Provide timely drug therapy for health plan members by reviewing and processing prior authorization requests using clinical judgment and medical policy.
• Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria
• Report to utilization review statistics to corporate compliance committees
• Review data and summarize daily utilization review numbers
• Responsible for tracking compliance of review cases
• Provide clinical guidance and support to the assigned pharmacy technicians
• Knowledge of drug coding (NDC, GCN, GPI and USC) and NCPDP claims adjudication systems
• Review guideline criteria for prior authorization and non-formulary drugs in support of Pharmacy and Therapeutics Committee function and pharmacy benefit design.
• Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practices
• Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Hiring Requirements
• Bachelor's degree or advanced degree
• 3+ years of experience in related field.
• Current states pharmacy license.
Salary Range
$118,691.00 - $189,906.00
Skills
Clinical Compliance, Drug Coding, Drug Information, Medical Knowledge, Medical Policy, Medical Prescriptions, Medicare, Medication Adherence, Medication Management, Medication Reconciliation, Medication Safety, Medication Therapy Management, Pharmacy, Pharmacy Operations, Pharmacy Regulation
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