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Clinical Pharmacy Specialist - Prior Authorization Team

Description

UPMC Health Plan is hiring a full-time Clinical Pharmacy Specialist to support the Prior Authorization Team within the Pharmacy Services department. This is a work-from-home position, working daylight hours Monday through Friday located anywhere in the United States.

Registration as a registered pharmacist (RPh), in the Commonwealth of Pennsylvania or eligibility for licensure by examination or reciprocity is required.

The Clinical Pharmacy Specialist provides clinical pharmacy expertise to the development, implementation and management of the pharmacy benefit. The clinical pharmacist assists in the management of pharmacy utilization and provides expertise in managing member care. These services will be provided in compliance with state and federal regulations, NCQA, standards, the mission, policies and procedures of Health Plan and Pharmacy Department. Individual should demonstrate professionalism and commitment to meet UPMCHP goals and objectives.


Responsibilities:

The Prior Authorization Pharmacist is primarily responsible for:

  • Performing the clinical review of Prior Authorization, Step Therapy, Quantity Limit, and all other pharmacy utilization requests in accordance with quality, timeliness, and efficiency standards.
  • Critically reviewing medication based prior authorization requests for approval/denial against standard criteria.
  • Taking calls from internal and external stakeholders as it pertains to the exception process, answering in a timely, accurate and professional manner.
  • Participating in the pharmacy appeals process through the review of cases and committee representation on hearings. Participate and contribute to other clinical and efficiency initiatives on and as needed basis.

Additional responsibilities include:

  • Administrative: Participate in meetings, committees, and work groups both internally and externally as assigned. Maintain a solid understanding of the requirements of the Pennsylvania Department of Health, DPW, CMS and the National Committee for Quality Assurance, specifically as they relate to the expectations of pharmacy operations. Ensure compliance with regulatory and accreditation requirements of clinical functions.
  • Communication: Foster and maintain collaborative relationships with internal and external customers. Communicate pharmacy information as appropriate to members, employer groups, and providers. Develop communication materials to providers, including discussions regarding formulary changes/adherence, health education, medication compliance, and trend management.
  • Teaching and Education: Mentor students and assist in precepting for the residency program (if applicable).
  • Special Skills/Ability to Interact: Have ability to function independently, but support team concept. Behavior denotes reliability as demonstrated by prompt attendance and timeliness completing designated workload and follow-up. Conveys and maintains professional image while interacting with coworkers, providers, and clients. Honor client and patient confidentiality.
  • Provide innovative ideas for new and existing clinical program development, utilization management, formulary management, provider education, and therapeutic substitution programs. Work with employer clients, account management, and sales in meetings as assigned to improve the understanding of the pharmacy benefit, as well as offering recommendations.
  • Develop and revise various formularies for each line of business including sending communications, training of identified departments, updating all brochures, updating appropriate websites, and submitting change forms. Review new drugs in a timely manner and submit change forms as appropriate. Research adequately and be properly prepared for all P&T Committee meetings, ensuring all recommendations for both new drugs and new policies are appropriate and have been discussed with subject matter experts. Present these assignments succinctly and at a suitable pace, and answering relevant questions.

Qualifications

  • Bachelor of Science Degree in Pharmacy, and/or Doctor of Pharmacy Degree (Pharm.D.) from an accredited U.S. School of Pharmacy.
  • Experience in pharmacy benefit management, insurance, managed care preferred and be knowledgeable in therapeutic interventions and other cost containment programs.
  • Effective communication skills, both written and oral.Must have strong analytical ability and organizational skills.
  • Computer literacy for pharmacy programming, word processing, data management.
  • Assessment of job related skills and competency will be reviewed annually via daily functioning, job-related documentation, department based competency programs, and continuing education activities.

Preferred Experience:

  • (1) PA Pharmacist - Managed care residency or 1-3 years managed care experience, preferably in the development and execution of multiple utilization management techniques such as prior authorization, step therapy, quantity level limits, and other dose optimization techniques.
  • (2) Product Development - Managed care residency or 1-3 years managed care experience in formulary development and management, especially in Medicare, Medicaid, Commercial and/or Exchange lines of business.
  • (3) Care Management - Managed care residency or 1-3 years managed care experience or at least 3 years of direct patient pharmacy practice experience, engaging in counseling and clinical services.


Licensure, Certifications, and Clearances:
Registration as a registered pharmacist (RPh), in the Commonwealth of Pennsylvania or eligibility for licensure by examination or reciprocity.Continuing Education requirements met each bi-annual cycle for re-licensure, as evident by obtaining a minimum of 30 hours of continuing education every 2 years in structured pharmaceutical education as necessary by the state board
 

  • Pharmacist

    UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct