- Accountable for the review of Medicare and Medicaid prior authorizations and coverage determination requests to ensure the efficient delivery, clinical appropriateness, and optimization of care; including assisting in the management of work process flows.
- Applies a comprehensive clinical knowledge of pharmacy claims and formularies across the lines of business. Has knowledge of all products and all types of claims.
- Works closely with department leadership and Medical Directors to ensure compliance within all areas of coverage determinations.
- Manages and develops direct reports who include other management or supervisory personnel and ensures the delivery of superior pharmacy operations service and member satisfaction by providing timely and accurate resolution to claims.
- Develops, manages, and monitors performance for production, quality, and compliance. (i.e.: clinical criteria justifications, prior authorization / coverage determination decisions and application of department workflow processes)
- Drives departmental initiatives to eliminate barriers impacting claims resolution. Works collaboratively with other leaders and departments to ensure consistency in workflow processes and that departmental goals all support the corporate goals.
- Facilitates the development and implementation of department goals and performance standards.
- Plans and implements strategies leading to the achievement of targeted outcomes and goals and assists in developing short range plans for the department.
- Partners with department leadership to review, develop and ensure execution on departmental policies and procedures in conjunction with all state, federal, and contractual requirements and that authorization/coverage determination requests are handled within all federal and state regulatory compliance time frames.
- Reviews pharmacy claims data to identify possible clinical savings opportunities.
- Effectively use project plans to focus work and ensure deadlines are met; including crafting and the execution of effective AOS engagement strategies.
- Lead and present at assigned committees/tasks.
- Assists with coverage of night and weekend rotation as needed.
- Performs special projects as assigned.
- Required A Bachelor's Degree in Pharmacy
- Preferred A Doctor of Pharmacy (PharmD)
- Required 3 years of experience in licensed pharmacist role or successful completion of a PGY-1 Residency Program
- Required 1 year of management experience
- Required Other Experience in managed care
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated written communication skills
- Intermediate Ability to influence internal and external constituents
- Intermediate Other Ability to use pharmaceutical and medical reference, literature to provide drug information to the health plan
- Intermediate Other Ability to evaluate financially the impact of drug products
- Intermediate Ability to communicate and make recommendations to upper management
- Intermediate Ability to lead/manage others in a matrixed environment
- Intermediate Knowledge of healthcare delivery
- Intermediate Ability to create, review and interpret treatment plans
Licenses and Certifications:
A license in one of the following is required:
- Required Other Licensed pharmacist in state of operation
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Outlook