Clinical Pharmacist
Job Summary
The Clinical Pharmacist is responsible for reviewing prior authorization requests for medications under the medical benefit. This role involves developing clinical criteria and medical policies while ensuring compliance with CMS and NYSDOH regulations. The position requires collaboration with prescribing physicians and Medical Directors to evaluate clinical rationale and review treatment trends.
Responsibilities
- Monitor and review prior authorization requests
- Develop clinical criteria and medical policies
- Ensure compliance with CMS and NYSDOH standards
- Analyze drug trends and monthly quality reports
Required Skills
- Pharmacy degree and NY State License
- 1+ year prior authorization experience
- Clinical knowledge of pharmaceuticals
- Critical thinking and analytical skills
- Proficiency in Microsoft Office Suite
Job Details
Duties & Responsibilities:
- Monitor and review prior authorization requests for medications
- Calculate appropriate billable units based on dosing, indication, weight, BMI, and other clinical considerations
- Develop clinical criteria and medical policies for the review of medications
- Ensure all clinical criteria is in compliance with Center of Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH)
- Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
- Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH
- Review monthly reports and provide feedback on trends, ideas for efficiency, and innovation
- Ability to work well in a team environment and be a team player
- Additional duties as assigned
Minimum Qualifications:
- Pharmacy degree from an accredited school of pharmacy
- Registered Pharmacist in the state of New York with a license in good standing
- Minimum of 1 year experience conducting prior authorization reviews
- Strong clinical knowledge of pharmaceuticals and disease states
- Strong clinical writing and verbal skills
- Demonstrated critical thinking and problem-solving skills
- Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits
- Passion for learning and promoting the profession of pharmacy
Preferred Qualifications:
- PGY1 Managed Care Residency (optional)
- Knowledge of regulations of the Centers for Medicare and Medicaid Services
- Ability to lead large and small working meetings
- PC Skills with Microsoft Outlook, Word, PowerPoint, and Excel (Pivot tables)
Regulatory or Compliance activities:
- Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.