FairosRx Prior Authorizations Pharmacist (Full-Time)
欧库网公司是一家创新性企业，致力于降低医疗保健成本。我们是一个热情的群体，不牺牲经验而关心负担得起的医疗服务。我们努力使医疗保健更智能，简单和经济效率。我们提供行业领先的能力，以谈判驱动杆来控制医疗费用不断上升，同时采取专注于经验的方式改善我们的服务者的健康和福祉。我们自豪地表现出基于"外向思维"哲学的紧密结合文化，强调同情心，相互尊重和将彼此视为全人类。我们有雄心勃勃的愿景，并迅速发展。我们正在寻找那些对我们的增长感到兴奋的人员，希望在快速发展的环境中壮成长，并且热衷于与我们一起培养自己的技能和职业生涯。工作描述 职位标题：先前授权药剂师部门：临床 （运营）报告给：临床总结职务副主席 预先授权药剂师负责对药店的预先授權申请进行临床审查和评估，以确保根据会员利益，基于证据的临床标准以及客户特定覆盖政策适当使用药物。该职位通过及时确定覆盖性，识别临床合适的治疗替代品，协调上诉和与处方人员，成员和内部利益相关者合作支持高质量，经济效率的医疗保健。预先授权药剂师还通过支持利用管理倡议，制定和维护临床标准，确定节省成本的机会以及在临床计划中持续提高质量来提供临床领导。基本职责与责任临床审查和使用管理 ·根据会员福利计划，临床指南，客户政策和监管要求评估和评估预先授權请求。· 在保持高水平的临床质量和准确性同时，在既定转型时间要求内完成预先授予审查。· 根据证据来确定所需药物治疗的医疗必要性和合适性。· 鉴定可优化治疗和成本效益高的药物管理的机会。
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The OccuNet Company is an innovative company striving to reduce the cost of healthcare. We are a passionate group of people that care about affordable access to healthcare without sacrificing experience. We strive to make healthcare more intelligent, streamlined, and cost-effective. We offer industry-leading capabilities on negotiations-driven levers to contain rising healthcare costs while taking an experience-centric approach improving the health and well-being of those we serve. We pride ourselves on our tight knit culture based on the ‘outward mindset’ philosophy, emphasizing empathy, mutual respect, and seeing each other as “whole people.” We have an ambitious vision and are growing quickly. We are seeking team members who are excited about our growth, seeking to thrive in a fast-paced environment, and enthusiastic about developing their skills and career alongside us.
Job Description
Job Title: Prior Authorization Pharmacist
Department: Clinical (Operations)
Reports To: Sr Vice President of Clinical
Position Summary
The Prior Authorization Pharmacist is responsible for the clinical review and evaluation of pharmacy prior authorization requests to ensure appropriate medication use in accordance with member benefits, evidence-based clinical criteria, and client-specific coverage policies. This position supports high-quality, cost-effective pharmaceutical care by making timely coverage determinations, identifying clinically appropriate therapeutic alternatives, coordinating appeals, and collaborating with prescribers, members, and internal stakeholders.
The Prior Authorization Pharmacist also provides clinical leadership to the pharmacy operations team by supporting utilization management initiatives, developing and maintaining clinical criteria, identifying cost-saving opportunities, and driving continuous quality improvement across clinical programs.
Essential Duties and Responsibilities
Clinical Review and Utilization Management
- Review and evaluate prior authorization requests in accordance with member benefit plans, clinical guidelines, client policies, and regulatory requirements.
- Complete prior authorization reviews within established turnaround time requirements while maintaining high standards of clinical quality and accuracy.
- Apply evidence-based clinical criteria to determine medical necessity and appropriateness of requested drug therapies.
- Identify opportunities for therapeutic optimization and cost-effective medication management while maintaining clinical efficacy and patient safety.
- Collaborate with prescribing providers to recommend clinically appropriate, cost-effective formulary alternatives when applicable.
- Provide clinical recommendations that promote appropriate medication utilization and adherence to formulary management strategies.
Appeals and Clinical Consultation
- Coordinate the clinical review of appeals related to pharmacy benefit determinations.
- Communicate coverage decisions and clinical rationale to providers, members, pharmacy staff, and other stakeholders.
- Receive and initiate telephone calls with providers and members to obtain additional clinical information or provide clinical consultation regarding pharmacy benefit decisions.
- Serve as a clinical resource for member advocates, account executives, and other internal departments by providing guidance on pharmacy benefit policies, coverage criteria, and medication-related questions.
Clinical Program Development
- Assist in the development, implementation, and maintenance of prior authorization criteria, clinical guidelines, and utilization management programs using principles of evidence-based medicine.
- Support formulary management initiatives, including step therapy, quantity management, and other clinical programs designed to improve quality and control pharmacy costs.
- Evaluate emerging clinical literature and therapeutic guidelines to support ongoing updates to coverage criteria.
Customer Service
- Respond to inquiries from members, providers, pharmacy staff, clients, and internal departments regarding pharmacy benefits, authorization status, formulary requirements, and coverage determinations.
- Communicate professionally and effectively with all stakeholders.
Data Analysis and Reporting
- Analyze pharmacy utilization data to identify prescribing trends, utilization patterns, and opportunities for cost savings and quality improvement.
- Generate, review, and interpret prior authorization reports.
- Present findings and recommendations to clinical leadership and other stakeholders as appropriate.
- Monitor key performance indicators and identify opportunities to improve clinical and operational performance.
Leadership and Quality Improvement
- Continuously evaluate and improve prior authorization workflows and drug utilization management processes to enhance efficiency, quality, and member experience.
- Provide clinical leadership and mentorship to clinical associates.
- Motivate and support clinical staff to achieve or exceed established productivity, quality, and service standards.
- Assist with onboarding, education, and ongoing training of clinical staff regarding new clinical programs, policies, procedures, and regulatory requirements.
- Participate in quality assurance activities, audits, accreditation initiatives, and process improvement projects.
Compliance
- Ensure all clinical activities are conducted in accordance with HIPAA, client requirements, accreditation standards (including NCQA & URAC where applicable), and federal and state regulations.
- Maintain complete, accurate, and timely documentation within pharmacy management systems.
- Perform additional duties and special projects as assigned.
Qualifications
Education
· Bachelor of Science in Pharmacy (BSPharm) or Doctor of Pharmacy (Pharm.D.) degree from an accredited college of pharmacy.
Licensure
- Active, current, and unrestricted Pharmacist license.
- Licensure in additional states may be required based on business needs.
Experience
Required
- Minimum of one (1) year of direct prior authorization or utilization management experience.
- Experience applying evidence-based clinical guidelines in pharmacy practice.
Preferred
- Pharmacy Benefit Management (PBM) experience.
- Experience reviewing pharmacy prior authorizations and appeals.
- Experience with formulary management, drug utilization review (DUR), and medication therapy management.
- Experience supporting NCQA, URAC, or other accreditation standards.
Knowledge, Skills, and Abilities
- Strong clinical knowledge of pharmacotherapy and evidence-based medicine.
- Knowledge of pharmacy benefit management operations and utilization management principles.
- Working knowledge of the Medi-Span drug database, including GPI drug classification.
- Excellent clinical judgment and critical thinking skills.
- Proficiency with Microsoft Excel, Microsoft Word, and pharmacy management systems.
- Excellent written and verbal communication skills.
- Strong interpersonal and customer service skills with the ability to effectively communicate with providers, clients, members, and internal stakeholders.
- Strong organizational skills and the ability to prioritize multiple competing responsibilities while meeting established deadlines.
- Ability to work independently and collaboratively within a multidisciplinary team.
Core Competencies
- Clinical Excellence
- Evidence-Based Decision Making
- Customer Focus
- Leadership and Team Development
- Collaboration
- Critical Thinking
- Quality Improvement
- Data Analysis
- Communication
Work Environment
This position is primarily performed in an office or remote office environment and requires prolonged periods of sitting while working on a computer. Responsibilities include frequent telephone communication and interaction with providers, members, pharmacy staff, clients, and internal stakeholders.
Work Schedule
- Full-time
- Monday through Friday
- Standard business hours with flexibility to meet operational needs.
Compliance
The Prior Authorization Pharmacist is responsible for performing all duties in accordance with company policies and procedures, client contracts, accreditation standards (including NCQA and URAC, where applicable), HIPAA privacy and security requirements, and all applicable federal and state laws.
Culture and Opportunities
- We pride ourselves on our outward mindset – supporting each other and putting the team and the clients we serve first
- High-growth environment with clear opportunities for career growth
- Welcoming atmosphere and culture
Benefits
- 401(k) with matching
- Dental insurance
- Health insurance
- Vision insurance
- Health savings account
- Paid time off
Originally posted on Himalayas