Clinical Pharmacist (Montvale NJ)Position Summary:The Clinical Pharmacist - Prior Authorization ensures clinical prior authorization and appeal determinations are completed in accordance with covered plan design while ensuring clinically appropriate pharmacy care and sustainable clinical savings for clients. This role supports EmpiRx Health's Population Health Management model through collaboration, evidence-based decision-making, and proactive engagement with providers to drive optimal clinical and financial outcomes.
What You'll Do: Key Responsibilities:Clinical Review & Determinations- Act as a clinical expert on prior authorization review and evaluation in accordance with clinical criteria and covered plan design.
- Conduct thorough evaluations and resolutions of assigned clinical reviews by performing in-depth case analyses and collaborating directly with physicians, in alignment with EmpiRx Health's Population Health Management framework.
- Perform peer-to-peer reviews with providers as needed or when requested.
- Convey clinical determinations promptly within established turnaround time requirements to prescribers, members, and healthcare professionals following established approval and denial protocols.
Clinical Oversight & Quality Assurance- Monitor and proactively identify clinical interventions to ensure clinical savings guarantees are met.
- Review and evaluate current clinical literature to support decision-making and provider recommendations.
- Participate in continuous quality improvement initiatives to streamline review processes and enhance member care.
- Stay informed about EmpiRx Health formulary changes, clinical programs, and internal policies and protocols.
Collaboration & Communication- Provide guidance and support to members, providers, and healthcare professionals regarding clinical inquiries.
- Collaborate with clinical technicians and Clinical Account Executives to facilitate review requests, resolve escalations, and answer inquiries.
- Act as a clinical resource for internal staff, supporting staff training and development as needed.
- Collaborate cross-functionally with internal teams for claim/data review, clinical interventions, and provider, member, or client support as required.
Technology & Documentation- Proficiently utilize pharmacy management software for documentation and communications.
- Proficiently utilize Microsoft Office tools to support analysis and reporting.
- Utilize external clinical and drug information databases (e.g., IPD, UpToDate, MediSpan) to support reviews, decisions, and awareness of emerging drugs.
What You Need:Experience, Qualifications & RequirementsEducation- Pharm.D. degree from an accredited college of pharmacy (Preferred).
Experience- Minimum of 3 years of pharmacy experience in clinical, PBM, or managed care settings.
Prior experience with prior authorization, utilization management, or health plan operations preferred.
Licensure & Certifications- Active Pharmacist License in good standing (Required).
- MTM or other specialty certifications preferred.
Skills & Competencies- Strong clinical judgment and analytical skills.
- Exceptional written and verbal communication with a comfortability of speaking with providers and medical staff.
- High attention to detail and accuracy in documentation.
- Excellent organizational and multitasking abilities.
- Proficient in Microsoft Office Suite and pharmacy systems.
- Ability to work independently and collaboratively in a fast-paced environment.
The expected salary range for this New Jersey position is between $102,997-$147,139. Total earnings may also include various incentive options.Actual pay will be adjusted based on experience, education,geographic location, and other job-related factors as permitted by law. Subject to program eligibility, this position qualifies for a robust suite of benefits including: Paid Time Off, a 401(k) program, Health Insurance including Dental & Vision coverage, Tuition Reimbursement, Health Savings Account, and an Employee Assistance Program.)Benefits And PerksSubject to program eligibility, this position qualifies for a robust suite of benefits including: Paid Time Off, a 401(k) program, Health Insurance including Dental & Vision coverage, Health Savings Account, and an Employee Assistance Program.
Note: This job description is a general outline of responsibilities and qualifications for the role. Additional duties may be assigned, and the position may evolve to meet the organization's needs.
