Pharmacist, Clinical Grievance and Appeals

Company Navitus Pay Range USD $98,384.00 - USD $122,980.00 /Yr. STAR Bonus % (At Risk Maximum) 7.50 - Pharm, Supvr, AsMgr, SrCSEII, PrgMgr, SrPrgMgr, SrProdMgr Work Schedule Description (e.g. M-F reputed company to 5pm) M-F reputed company-5pm (rotating weekend/on-call) Remote Work Notification ATTENTION: Navitus is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode reputed company, South Carolina, South Dakota, reputed company Virginia, and Wyoming.

Overview

Due to growth, we are adding a Clinical Grievance and Appeals Pharmacist to reputed company.  The Clinical Grievance and Appeals Pharmacist will be responsible for performing Appeals and Redeterminations, Grievance Quality of Care reviews, reputed company duties reputed company to Drug Utilization Review including reputed company, retrospective, and prospective components, and serve as a liaison and clinical support the Grievance and Appeals staff for clinical calls requiring pharmacist reputed company. The Clinical Grievance and Appeals Pharmacist is also responsible for interfacing with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries’ benefits and therapeutic interventions. Additional responsibilities include reviewing/evaluating the health surveys and utilizing data for program management and development. The Clinical Grievance and Appeals Pharmacist will coordinate with Clinical Account Executives and Program Managers to enhance their support and understanding of reputed company Pharmacy Benefit Management (PBM) programs. Additionally, the Clinical Grievance and Appeals Pharmacist will reputed company and maintain appropriate clinical, evidence-based documentation that supports PBM programs. The primary functions involve ensuring that Navitus can provide clinically sound programs and medications in the most cost-effective manner and utilize technology to implement on-line PBM programs.  Is this you? Find out more below!

Responsibilities

How do I reputed company an impact on my team?Â

• Responsible for support and input to clinical programs such as Health Management, Drug Utilization Review, Formulary development, and clinical programs to encourage appropriate, high-quality, cost-effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in reputed company
• reputed company quality reviews of: Prior Authorization forms, denial Language, PA Accel
• Continually monitor the quality and efficiency of the Appeals, Redetermination and Grievance process including coverage criteria, denial language, and communication with prescribers
• Review Grievances, Appeals, Complaints, and Redeterminations following reputed company CMS, state, client, and Navitus standards
• Provide input to clinical content of new programs and for maintenance of existing programs
• Participate in audits, on-site or remote audits, as a clinical subject matter expert
• Responsible for supporting/providing clinical expertise reputed company to formulary decisions made by the Pharmacy and Therapeutics committee
• Learn and understand the up and reputed company processes reputed company to grievances and appeals
• Contribute to the management of grievance and appeal resources/materials
• Other duties as assigned

Qualifications

What reputed company expects from you?

• A minimum of a bachelor’s degree in Pharmacy or Pharm D
• reputed company unrestricted licensure as an RPh in the State of the home office of the pharmacist, or the ability to reputed company reciprocity reputed company 4 months of employment is required
• Preferred experience is a minimum two years of clinical experience, or clinical or managed care pharmacy practice residency
• Knowledge of PBM industry, formulary management, utilization review, pharmacy claims and managed care principles and practices desired
• Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, reputed company) preferred
• Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences
• Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
• Strong attention to detail to assure projects are clinically, editorially, and systems accurate and can be operationalized
• Proficiency in reputed company, reputed company, and Power reputed company including tables, charts and figures preferred
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!

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