ABMS Board Certified Medical Director - Pharmacy

Company

Navitus

About Us

Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.

Pay Range

USD $201,052.00 - USD $251,315.00 /Yr.

Work Schedule Description (e.g. M-F 8am to 5pm)

M-F 8am-5pm

Remote Work Notification

ATTENTION: We are unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

Overview

Navitus Health Solutions is seeking a Medical Director to join our Health Strategies department supporting the states of Texas and Arkansas. 

 

The Navitus Medical Director serves as the medical expert within the Health Strategies Division to provide clinical leadership and guidance in support of clinical program development and execution, prior authorization (PA), grievance and appeals, and client directed initiatives. The Medical Director will assist the Health Strategies Division in assuring the prescription drug benefit is evidence based and provides clinical outcomes in a financially responsible manner in accordance with all applicable laws, regulations, and client expectations. Clinical policy development and oversight in support of prior authorization criteria, appeals and grievance determinations and the Centers for Medicare and Medicaid (CMS) regulatory requirements will be key to this position. An innovative, entrepreneurial spirit is desirable, and the ability serve as the voice of the prescriber across the PBM is integral. The Medical Director will work in conjunction with other Navitus Medical Directors to review adverse determinations and redeterminations as required by clients or state and federal regulations. The Medical Director will be located in Austin, TX and will serve as the Texas Provider leader for: Prescriber Engagement & Education to the Texas Association of Community Health Plans, The Texas Pharmacy and Therapeutics Committee, The Texas Clinical Workgroup Additional, national involvement in Health Services Outcome Research, Client Engagement, and clinical strategy will round out the position.

 

Is this you? Find out more below!

Responsibilities

How do I make an impact on my team? 

• The Medical Director will review High Cost claims affecting our Texas MCOs and will be a resource for plan physicians in understanding lower cost therapeutic alternatives
• Completing assigned medication utilization reviews (PA) and/or medical necessity appeals, for commercial clients, governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals as appropriate
• Proficiency in all Prior Authorization programs to support all lines of business including commercial, exchange, Medicaid and Medicare
• To provide peer to peer telephonic support to physicians/prescribers who require additional information regarding programs within the Health Strategies Division to include PA, Formulary, Utilization Management and Clinical Programs among others
• Clinical guidance in support PA criteria development, clinical program development, and product development
• Serving as the Texas Provider Representative to provide medical provider insight to formulary decisions, quality improvement projects, clinical quality metric oversight and new product development on the Clinical Quality Team and the New Product Development Committee
• Participate in inter-rater review activities and other quality oversight processes for internal Director UM decisions
• Providing weekend, evening and holiday coverage on a rotational basis as business needs dictate
• Participating in regulatory and mock audits, consultant presentations, prospective client opportunities and finalist presentations
• Resource for Clinical Programs and Provider engagement. Consult with Navitus Clinical Programs team on the use of Medical Claims data
• Other duties as assigned

Qualifications

What our team expects from you?

• Must be a graduate of an accredited Medical School
• Must be ABMS Board Certified in a recognized medical specialty, preferably in Internal Medicine
• Possess an unrestricted active license to practice medicine issued by the State Board of Licensure or the State Board of Osteopathic Examiners
• Licensed in the State of Texas as a medical physician or able to get licensed in the state of T