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Pharmacy RN Consultant

Company: DXC
Location: Madison
Posted on: December 4, 2019

Job Description:

Job Description: The Pharmacy RN Consultant will review Medicaid Prior Authorizations based on medical necessity in accordance with State policy guidelines, provide guidance and support for Medicaid Providers when appropriate, and act as a clinical SME (or liaison) for internal DXC entities. Note: This is not a patient facing position. Primary Job Responsibilities: Adjudicating pharmacy prior authorizations based on medical necessity and eligibility, in accordance with State policy guidelines and accepted pharmacy practices. Reviewing and evaluating prior authorization submissions utilizing multiple computer systems, and when appropriate seeking additional information or clarification from requesting Provider Entering prior authorization outcome into the Medicaid Management Information System (MMIS) for processing. Participation in monthly meetings which include DXC leadership, operational staff support, clinical peers and State stakeholders. Providing assistance and education to the provider community related to specific prior authorization submissions, when applicable. Offering analysis and recommendations to DXC and State leadership on methods and potential process improvements related to the administration and application of the pharmacy program. Review communications to providers and members on new/revised policies. Additional Responsibilities: Monitor the pharmacy PA work queue for Hepatitis C and other drug requests. Maintain no more than a 10 business day PA inventory of Hepatitis C and other drug requests. Review PA requests for completeness/accuracy. Return to provider requesting missing information, as needed. Summarize clinical information from PA documentation and provide an adjudication recommendation (e.g., approve, deny, or return). If recommendation is to deny or return, prepare draft message. Initiate/complete peer-review of PA request summaries/recommendations. Provide PA request summary/recommendation to DHS Pharmacist/Medical Director for approval. Submit final PA adjudication. Maintain/update Hepatitis C and other drug requests tracking documentation throughout PA adjudication process. Generate Hepatitis C and other drug request PA statistics/metrics and report to clinical team monthly. Review/prepare detailed responses for member appeals related to Hepatitis C PAs for DHS Pharmacist approval. Initiate provider contact (e.g., prescriber, pharmacy) to obtain additional documentation for a PA request, as needed. Monitor dispensing of Hepatitis C and other drug requests and initiate provider contact to generate renewal PAs, as needed. Develop/implement a member post treatment tracking process. Contact HMO case coordinator or other entity, when appropriate. Other: Summarize clinical information from PA documentation and provide an adjudication recommendation (e.g., approve, deny, or return) for DHS consultant review, as assigned. If recommendation is to deny or return, prepare draft message. Evaluate and recommend revisions to existing PA clinical criteria (e.g., Botox, Cytokine/CAM) and/or create new PA clinical criteria, as assigned. Support analytical work related to clinical assessments and policy development. Evaluate and develop clinical policy recommendations (e.g., vitamins, compound drugs) in coordination with pharmacy policy analysts. Develop/strengthen working relationships with HP and DHS teams. Ability to make judgments in demanding situations Ability to react to frequent changes in duties and volume of work Ability to logically organize details Comfortable accepting responsibility for medium to large scale projects involving multiple resources and spanning many months from start to finish Ability to manage multiple concurrent activities Licenses and Certifications: Minimum RN License in the State of Wisconsin

Keywords: DXC, Madison , Pharmacy RN Consultant, Healthcare , Madison, Wisconsin

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