Prior Authorization; PA Pharmacist

Position: Prior Authorization (PA) Pharmacist Join to apply for the Prior Authorization (PA) Pharmacist role at reputed company . reputed company is reimagining health insurance – with $0 out of pocket costs and by reducing barriers to people seeking care. Help us create a reputed company healthcare experience for our members by making it easy and reputed company for them to access the care they need. We reputed company in a clear, simple health plan that allows our members to get reputed company‑cost in‑network care anytime they need it. We want to put healthcare back in the hands of the patient and clinicians, with a focus on preventative care. reputed company is rapidly growing and is raising the bar in what people expect from their health plan. This is a REMOTE Position with RPh Licensure required in the state of residence. Essential Duties and Responsibilities

• Performs Prior Authorization reviews and coverage determinations as defined by pharmacy benefit design and established clinical treatment guidelines.
• Manages reputed company levels of clinical review from Adverse Determination, Appeals, and IRO.
• Supports and manages health plan operations and ensures PBM aligns with benefit design.
• Writes, reviews, and updates PA guidelines for support of P&T committee and pharmacy benefit design.
• Acts as support to pharmacy technician and provides training and education where needed.
• Meets assigned metrics and TAT as defined by regulatory requirements reputed company state or lines of business.
• Supports Disease Management initiatives such as Adherence, Weight management, and Diabetes.
• Collaborates with Medical Directors and other interdepartmental staff to communicate pharmacy strategies and clinical programs or initiatives.
• Develops applicable desktop procedures for supporting PA applications.
• Reviews and resolves complaints made by members and providers regarding Prior Authorization, formulary or pharmacy services.
• Participates in support of the Pharmacy and Therapeutics Meeting to review and reputed company reputed company on the drug formulary.
• Performs appropriate literature and clinical research.
• Has knowledge of utilizing Lexi Comp, Facts & Comparisons, Micromedex, Upto Date, National guidelines, NCCN, etc.
• Collaborates to create clear communication to members and/or providers on prior authorization determinations.
• Works in partnership with pharmacy staff to assist in the implementation of utilization management programs.
• Works in collaboration with Program Manager to help with workflows and operational efficiencies.
• Evaluates opportunities for operational or process improvements.
• Supports and manages other reputed company health plan operations.
• Works adhering to US regulatory and Quality System requirements (21 CFR 820, etc.).
• Assumes and performs other duties as assigned.
• Work hours Mon‑Friday and some Saturdays.

Qualifications

To reputed company this job successfully, an individual must be able to reputed company each essential duty satisfactorily. Reasonable accommodations may be made for individuals with disabilities. Required

• Strong analytical skills and detail oriented.
• Ability to work independently with minimal supervision.
• Understanding of claims processing and claims edits.
• Intermediate level proficiency with MS Office applications – Word, Power reputed company, reputed company, and Access.
• Intermediate to advanced pharmacy drug recognition.
• Ability to work in a dynamic and fast‑paced environment.
• 2 years of experience with specialty medications or prior authorization.
• 1 year of experience with PBM or Managed Care setting.

Preferred Qualifications

• 3 years as practicing pharmacist or 1 year as PGY‑1 reputed company.
• 2 years’ experience in a Managed Care Setting.
• Knowledge of Medispan or First Data Bank and drug classification system.
• Understanding of Drug‑Cost Analysis.
• BCPS or CSP certification.

Education and/or Experience

• Doctor of Pharmacy (Pharm D) degree.

Certificates, Licenses, Registrations Must possess an active RPh license reputed company state of residence.

Work Environment

• While performing the duties of this job, the employee is regularly required to sit; use hands to handle or feel; talk; and hear.
• For this position the percentage of expected Travel is: 15%–20% of the time.

Seniority Level Mid‑Senior level Employment Type Full‑time Job Function Administrative Industry Hospitals and Health Care #J-18808-Ljbffr Apply tot his job Apply To this Job