Clinical Utilization Management Pharmacist

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. 

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Job Summary
Under the direction of the Pharmacy Utilization Management (UM) Supervisor, the Clinical Pharmacist is responsible for reviewing, processing and managing the daily caseload of pharmacy prior authorization (PA) requests for coverage determinations (CD), and exceptions. The Clinical Pharmacist ensures timely disposition of reviews for CD and exceptions by adherence to established timeframes. The Clinical Pharmacist consults as required with THP Medical Directors (MD) on prior authorization that fails to meet drug prior authorization (PA) criteria for coverage.

Job Description
• Performs case reviews in automated prior authorization (Auto PA) tools and guides the case through the entire process to either approval or denial to ensure all coverage determinations and notices are consistent with applicable regulatory and accreditation requirements and turnaround times
• Provides all aspects of clinical support needed to perform drug prior authorization (PA) requests and consults as required with THP Medical Directors (MD) on cases that fail to meet coverage criteria
• Communicates daily with members, providers and other external customers regarding status and disposition of cases
• Oversees and addresses any quality issues with pharmacy technicians and confer with other clinical pharmacist on review questions
• Communicate with UM staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage determinations within timelines developed by all accrediting and regulatory guidelines
• Facilitates communication between Pharmacy UM department and other internal Tufts Health Plan departments by acting as a liaison or committee member on the development or implementation of new programs
• Performs other roles/duties and projects as assigned by the Pharmacy UM Supervisor or Manager
Requirements
EDUCATION: (Minimum education & certifications required)
• A minimum of a Bachelor of Science degree in Pharmacy or PharmD
• Current registration and good standing with the Board of Pharmacy
EXPERIENCE: (Years of experience)
• A minimum of 3 years full-time experience as a pharmacist, preferably PBM and/or managed care setting
• Expert knowledge of the principles and practices of pharmaceutical science. Working knowledge of Federal and state controlled substance and pharmacy laws, rules and regulations
• Knowledge of drug coding (NDC, GCN, GPI and USC) and NCPDP claims adjudication systems
• Previous working knowledge of MedHOK, RxClaim, CCMS and CAS system a plus
• Knowledge of or experience with Medicare Part B & D, Medicaid and Drug Utilization Management
• Prior authorization experience, including reviewing drug use criteria for medication approval
SKILL REQUIREMENTS:
• Requires analytical ability to independently research/ summarize data on drug utilization and spend
• Excellent written and verbal communication skills
• Strong PC skills with MS Office (Word, Excel, PowerPoint & Access) and ability to learn/use new database and reporting applications
• High degree of professionalism and confidence
• Ability to recognize politically sensitive issues and utilize diplomacy
• Ability to interact effectively with all levels of management
• Must be self-motivated and capable of working independently with minimal supervision
• Must be capable of organizing, facilitating and managing several projects simultaneously
• Must be flexible and able to constantly review and reset priorities; often daily

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Provides subject