Clinical Pharmacist

Description:

Description :

Position Summary

The Pharmacist/Clinician is an operation-based role that conducts criteria based & clinical review of medical data collected to perform prior authorization as per policy and procedure. The Pharmacist/Clinician will apply clinical knowledge to plan approved criteria for reviews of cases. This role will work from client supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Authorization team and member services department, as well as provide on-call after hours availability for urgent PA request as needed.

Duties

1.) Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols. One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes. (60%)

2.) Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements. Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations. (25%)

3.) Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business. (10%)

4.) Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed. (5%)

Experience

Required: 0 to 3 years

Preferred: 3 to 5 years

Required Skills & Other Minimum Required Qualifications:

Licensed Registered Pharmacist

Knowledge of Microsoft Office Suite: Excel and Word required; Access, Outlook, PowerPoint, Visio preferable. Keyboard skills essential.

Must be able to multitask and utilize multiple system applications simultaneously.

Must be able to utilize available resources independently and provide high quality work.

Must demonstrate problem solving ability and attention to detail.

Ability to adapt and change with workflow and shifting priorities.

Ability to work effectively in a team environment and provide mentorship to non-clinical staff on the PA team.

Must possess excellent written, verbal, grammar, and listening communication skills.

Must be able to effectively communicate with a diverse customer base (internal and external) in a friendly and confident manner.

Ability to maintain confidentiality of PHI (Protected Healthcare Information).

Essential Functions:

1. Regular and predictable attendance

2. Colleague will be required to work mandatory overtime/extended work week when needed

3. Colleague will be required to travel when needed

4. Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers.

5. Adhere to all policies and procedures

6. Attend on going training and development meetings

Physical Requirements:

1. Sits at desk for long periods of time (up to 100%)

2. Talking on phone for extended periods of time (up to 100%)

3. Computer use for extended periods of time (100%)

4. Reading a computer screen (up to 100%)

5. Light lifting of less than 10 lbs

Work Environment

Work in a climate-controlled, smoke-free internal environment; work to be performed regularly in a client location or from an approved work-from-home location.

A broadband connection and a smartphone are required.

Note :

Shifts available (Sun-Thurs or Tues-Sat):

10:30am-7pm CST

11am-7:30pm CST

11:30am-8pm CST

Training dates: November 4th - December 13th, 2024; training time: 8am to 4:30pm CST M-F.