The Clinical UM Pharmacist is a dynamic position responsible for the review of prior authorizations for medications requested under the medical benefit. Additionally, the Clinical UM Pharmacist is responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly report for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine. The Clinical Pharmacist works directly with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions.
Duties & Responsibilities: • Monitor and review prior authorization requests for medications
• Calculate appropriate billable units based on dosing, indication, weight, BMI and other clinical considerations
• Develop clinical criteria and medical policies for the review of medications
• Ensure all clinical criteria is in compliance with Center of Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH)
• Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
• Perform and present drug utilization reviews (DUR) on medical benefit medications to assess clinical appropriateness, safety, and cost-effectiveness
• Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH
• Work across departments as needed to complete Utilization Management reviews
• Review monthly reports and present on trends, ideas for efficiency/innovation, and medical spend
• Ability to work well in a team environment and be a team player
• Additional duties as assigned or required
Minimum Qualifications:- Pharmacy degree from an accredited school of pharmacy
- Registered Pharmacist in the state of New York with a license in good standing.
- Minimum of 1 year experience conducting prior authorization reviews
- Strong clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews
- Strong clinical writing and verbal skills
- Demonstrated critical thinking and problem-solving skills.
- Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits
- Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities
Preferred Qualifications: - PGY1 Managed Care Residency (optional)
- Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations.
- Ability to lead large and small working meetings.
- PC Skills with Microsoft Outlook, Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables).
License or Certification: Licensed pharmacist in the state of NY in good standing.
Regulatory or Compliance activities: Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.
Hiring Range*:
- Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430
- All Other Locations (within approved locations): $88,700 - $131,920
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
*The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
