Job ID 1088336
Position Purpose: Provide timely drug therapy for Medicaid health plan members by processing prior authorization and medical necessity requests
- Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria
- Responsible for setting criteria for medication analysis, coordinate reports to clients, meet regulatory reporting requirements for drug utilization review and fraud and abuse reporting
- Develop clinical criteria for review of non-formulary or non-preferred drug lists medications and communicate recommendations to clients
- Oversee the drug utilization review and medication therapy management programs at the assigned plan to meet Medicare Part D requirements and develop systematic reviews of prescription claims to meet strategic initiatives
- Develop clinical edits effective at the point of sale to enhance appropriate drug utilization based on evidence-based criteria
- Provide clinical guidance and support to the assigned pharmacy technicians
- Develop and 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
Education/Experience: Bachelor’s degree or advanced degree (PharmD., M.S) in pharmacy. 3+ years of retail or hospital pharmacy experience or 1+ years of managed care pharmacy experience . Clinical pharmacy experience in managed healthcare preferred.
License/Certification: Current state’s Pharmacist license with no restrictions. Additional license may be required as need by state or contract.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.