Mgr Medical Pharmacy Policy

The Manager, Medical Pharmacy Policy is responsible for the development, implementation, and management of Healthfirst’s medical policies used to review prior authorizations for high-cost drugs. The manager will ensure that Healthfirst medical policies for high-cost drugs will support effective, evidence-based guidelines that align with the organization’s goals and regulatory obligations. They provide support and updates to leadership concerning various clinical roles, medical policy updates, clinical criteria updates and configuration for use by utilization management pharmacy team, medical pharmacy drug pipeline reports, medical policy preparation for committee stakeholders, criteria preparation for CMS UMAS (Utilization Management Annual Submission). This position is part of a multidisciplinary team and works closely with Healthfirst Medical Directors, Utilization Management leadership, Healthfirst’s IT leadership, regulatory and legal departments to ensure meaningful implementation of medical policies.

 Duties & Responsibilities:

• Develops, reviews, and updates medical policies and clinical guidelines to ensure they are evidence-based and aligned with best practices

• Responsible for clinical criteria updates, configuration and validation on prior authorization platform, perform testing and peer reviews of built criteria

• Assures public visibility of Healthfirst Pharmacy Medicare Medical Policies, accuracy of clinical information displayed, proper records keeping

• Assists senior manager, regulatory and compliance teams with clinical criteria preparation for law changes affecting high-cost drugs and clinical criteria as set forth by CMS or NYSDOH

• Assists senior manager, regulatory and compliance teams with clinical criteria preparation for clinical audits

• Assists UM clinical pharmacists with assessment of provider-submitted clinical information for clinical appropriateness based on predetermined clinical criteria

• Collaborates on policy reviews with committee stakeholders and clinical business unit stakeholders

• Assists with medical drug pipeline research, reports and presentations

• Additional duties as necessary

 Minimum Qualifications:

• Pharmacy degree from an accredited school of pharmacy

• Registered Pharmacist with a state license in good standing

• Work experience conducting medical policy writing and implementation

• Clinical knowledge of pharmaceuticals and disease states to support UM clinical pharmacists with assessment of provider-submitted clinical information for clinical appropriateness based on predetermined clinical criteria

• Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits

• Work experience requiring written and verbal clinical communication that is clear, concise, grammatically correct, and professional

Preferred Qualifications:

• Doctorate degree from an accredited institution

• Work experience requiring strong analytical and logic skills applied to clinical criteria, ability to configure criteria logic, pathways, and decision points accurately

• Experience with Clinical guidelines including but not limited to Milliman Care Guidelines, Hayes Clinical Guidelines, EMEDNY, CMS National and Local Coverage Determinations

• Demonstrated problem-solving, initiative taking, multitasking and critical thinking skills

• Passion for learning, promoting the profession of pharmacy, and interest in identifying and acting on opportunities for improvement or innovation and tracking annual policy renewals/approvals

• Demonstrated strategic mindset with a deep understanding of clinical practices, managed care regulatory requirements, and industry standards

• Experience leading large and small working meetings

• Experience with MS Office Suite, MS Teams, MS Outlook, SharePoint and Adobe Acrobat

Compliance & Regulatory Responsibilities:

• Assists in regulatory and compliance audits for all plans

• Ensure all medical policy activities are conducted in compliance with regulations

   

   

License/Certification: Licensed pharmacist in good standing 

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.  HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gen