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Pharmacist I, Clinical Prior Authorization

Company: Navitus Health Solutions LLC
Location: Madison
Posted on: August 7, 2022

Job Description:

Job Description Job Summary: The Pharmacist I, Clinical Prior Authorization will be responsible for: performing Prior Authorizations; perform duties related to Drug Utilization Review including concurrent, retrospective, and prospective components; and support Customer Care with clinical calls requiring pharmacist intervention. The Pharmacist I, Clinical Prior Authorization is also responsible for interfacing with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries--- benefits and therapeutic interventions, and reviewing/evaluating the health surveys and utilization data for program management and development. The Pharmacist I, Clinical Prior Authorization will coordinate with Clinical Account Executives and Program Managers to enhance their support and understanding of related Pharmacy Benefit Management (PBM) programs. Additionally, the Pharmacist I, Clinical Prior Authorization will develop and maintain appropriate clinical, evidence-based documentation that supports PBM programs. The primary functions involve ensuring that Navitus is able to provide clinically sound programs and medications in the most cost-effective manner and utilize technology to implement on-line PBM programs. The Pharmacist I, Clinical Prior Authorization is responsible for providing information as it relates to Navitus clinical goals and is a primary resource regarding all clinical pharmacy questions. Job Responsibilities: Responsible for support and input to clinical programs such as: Health Management, Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high-quality, cost-effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place. Participate in the Coverage Determination (Certification, Prior Authorization, Medical Exception, Exception to Coverage, etc.) process be reviewing all requests which are not clearly approvable based on specified criteria (algorithms), making all coverage denial determinations, and identifying themselves by first name, title, and responsibility at Navitus in relation to drug utilization management program administration Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers. Provide input to clinical content of new programs and for maintenance of existing programs. Complete all annual URAC training requirements Responsible for participating in core teams working on new program/ product development. Facilitation of communication and education to clients, members, and internal staff regarding clinical daily issues and objectives. Provide support to operational departments on the implementation of various PBM programs and daily functioning in support of member/patient quality of care. Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee. May review health care survey data for Medicare Part D qualified participants and/or perform phone consultations with Med-D enrollees; aid in documentation of calls; designate enrollees for repeat interaction. Assists Customer Care, Client Services, and other internal customers in responding to and resolving pharmacy-related inquiries from members, clients, providers, or pharmacies. Maintain open lines of communication with other functional areas/departments Provide effective communication of Navitus--- vision, mission, values, goals, and policies Participate in multi-departmental meetings and committees to accomplish projects Responsible for staying current with clinical literature and guidelines, and relaying those to the program development core teams Other related duties as assigned/required. Essential Background Requirements: Education: A minimum of a bachelor---s degree in Pharmacy or Pharm D. Current unrestricted licensure as an RPh in the State of the home office of the pharmacist or the ability to gain reciprocity within 4 months of employment is required. Experience: Two years--- work experience in a clinical setting, or clinical or managed care pharmacy practice residency preferred. Knowledge of PBM industry, formulary management, pharmacy claims and managed care principles and practices desired. Exceptional clinical skills and ability to apply sound clinical judgment to a variety of situations is necessary. Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline, Internet) preferred. Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences. Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution. Requires attention to details to assure projects are clinically, editorially, and systems accurate and can be operationalized. Proficiency in MS Word, Excel, Power Point including tables, charts and figures preferred. Key Skills/Competencies: Critical thinking/Problem-solving Judgment and Decision-making Influence and Persuasion Negotiation Skills and Conflict Resolution/Management Communication Skills (written, verbal/presentation and active listening) Teamwork/Collaboration Customer-Centric Skills, and ability to understand internal and external customers Strategic Thinking/Systems Aptitude Thinking Project Management and ability to prioritize continually/multi-task Leadership and ability to communicate a compelling vision for the program/products Understanding and coping with constant change Ability to build and manage relationships Ability to see the current state, in all its ambiguity Ability to work with people to change the current state to the desired state The ability to consistently interact cooperatively and respectfully with other employees Participate in, adhere to, and support compliance program objectives.

Keywords: Navitus Health Solutions LLC, Madison , Pharmacist I, Clinical Prior Authorization, Healthcare , Madison, Wisconsin

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