Job Description

Job Title: Pharmacy Clinical Review Specialist
Job ID: 180000KI
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: PHARMACY SRVCS
Location: 600 Grant St, Pittsburgh PA 15219

Description

Do you have a pharmacy experience and a passion for customer service?  If so, a role as a Pharmacy Clinical Review Specialist II with UPMC Health Plan may be the perfect fit for you.  In this role, you will oversee administrative and system processes that relate to pharmacy prior authorizations.  Additionally, you will manage the first line clinical review of prior authorization requests on behalf of physicians and UPMC Health Plan members. The Pharmacy Clinical Review Specialist will also collaborate with clinicians regarding supporting medical documentation in accordance with formulary guidelines while managing the quality review of requested prior authorizations.  This position will work a Monday through Friday schedule with a rotating Saturday requirement.  Additionally, this position will need to work overtime as business need dictates.

Responsibilities:
  • Act as a conduit of information between the Pharmacy Service Representatives and the clinical staff.
  • Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.
  • Develop and maintain the pre-logic and clinical criteria in support of the prior authorization determination process.
  • Interface with other departments and identify medical documentation in support of prior authorization requests.
  • Maintain or exceed designated quality and production standards.
  • Perform peer reviews of prior authorization requests.
  • Process requests and inquiries in accordance with all governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards.
  • Provide excellent internal and external customer service maintaining a second requests for information and customer complaint goal of zero.
  • Report and respond to escalate issues and concerns in a within twenty-four hours.
  • Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business.

Qualifications

  • High School diploma and two years of pharmacy claims, pharmacy tech, and/or other related experience in a physician practice, ancillary provider, or other relevant healthcare setting required OR one year of experience as a UPMC Health Plan Pharmacy Services Representative. 
  • Competent in pharmacy claims process operating system. 
  • Excellent knowledge in UPMC Health Plan internal department functions. 
  • Excellent knowledge of medical terminology, coordination of benefits, complaints and grievance guidelines and prescription drug utilization management requirements. Thorough knowledge in Microsoft Office and PC skills required. 
  • Organizational, analytical, interpersonal, and communication skills. 
  • Ability to prioritize and perform multiple tasks while maintaining designated production and quality standards.  
  • Staff is required to work scheduled overtime and be available for emergency overtime as business needs dictate. 
  • Staff is required to work a temporary, alternative schedule or shift as requested by supervisor.

Salary Range: $16.23 to $25.77

Union Position: non union

At UPMC, our shared goal is to create a cohesive, positive, experience for our employees, patients, health plan members, and community. If you too are driven by these values, you may be a great fit at UPMC!

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