Job Summary:

The Prior Authorization (PA) Pharmacist is responsible for utilizing pharmacy acumen, medication expertise, and healthcare payer knowledge related to drug-related prior authorization requirements and medication guidelines to support PA operations (in completing PA reviews), PA technology and automation, consultation on evidence-based guidelines and pharmacy policy, reporting and analytics, and quality management programs. The PA Pharmacist will collaborate with a team of pharmacy technicians and pharmacists in PA Operations.

Job Responsibilities (but not limited to):

• Practices within scope of licensure and maintains an active, non-restricted licensure.
• Performs clinical reviews of PA, Step Therapy, Quantity Limit, and all other pharmacy utilization requests in accordance with quality, timeliness, and efficiency standards.
• Performs coverage determinations and appeals requests according to criteria guidelines and in compliance with all state and federal regulations, including Medicare and Medicaid.
• Takes calls from internal and external stakeholders as it pertains to the PA process, answering in a timely, accurate and professional manner.
• Assists with monitoring day-to-day operations to ensure compliance with timelines and other operational functions.
• Serves as a resource and SME pertaining to the PA and appeals process.

• Researches and appropriately responds to PA guideline coding and rationale questions.

• Develops and implements clinical utilization criteria for new market entries and market updates utilizing evidence-based medicine principles.

• Makes strategic recommendations including benefit design and formulary analysis, provision of clinical drug information, Pharmacy & Therapeutics support and participation, rational drug formulary positioning, online system edits and restrictions, ongoing clinical product evaluations, and client pharmacy benefit utilization and performance trends as required.

• Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical, financial, and operational effectiveness and quality.

• Provides support for internal and external audits and surveys.

• Supports Fraud, Waste and Abuse program system oversight and communicates any suspected fraud discovered.
• Stays abreast of new regulations to ensure regulatory compliance of PA guidelines.
• Maintains privacy and confidentiality in all PA or appeal request interactions.
• Follows all state and federal regulations applicable to PBM operations and utilization management.

Qualifications: [PHARM Core 25 (a) (b) (c)]

• Bachelor of Science degree in Pharmacy required
• Pharmacy Doctorate (PharmD) preferred
• Managed Care or Clinical Residency program residency preferred
• Registered and in good standing with the Board of Registration in Pharmacy

Professional Experience:

• At least 2 years of recent job-related experience and/or training in pharmacy and/or prior authorization management or similarly related duties; or equivalent combination of education and job-related experience
• Must have a regard for confidential data and adherence to corporate compliance policy
• Expert knowledge of the principles and practices of pharmaceutical science, a working knowledge of managed care and policy development as well as working knowledge of state and federal controlled substances and related laws, rules, and regulations
• Working knowledge of managed care experience or Medicare experience required

Licenses/Certifications:

• Registered and in good standing with the Board of Registration in Pharmacy (multiple states will be required)
• Active, non-restricted pharmacist license

Specialized Skills:

• Strong clinical review competency
• Requires a high degree of initiative and excellent judgment to make decisions regarding clinical pharmacy issues in an extremely complex and often politically charged environment
• Requires excellent analytical skills necessary for program implementation, maintenance and enhancement and ability to analyze, assess and monitor physicians' prescribing trends and drug utilization patterns for clinical appropriateness and cost-effectiveness with the Plan's operations and goals
• Highly developed oral/written communication skills, self-motivation, and ability to work independently with minimal supervision are necessary
• Must be flexible and able to constantly review and reset priorities, often daily, and to handle multiple projects simultaneously
• Must be able to appropriately identify emergency situations and follow through with the appropriate protocol