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   Current UPMC employees must apply in HR Direct

Pharmacy Clinical Review Specialist I, Health Plan

Description

UPMC Health Plan is hiring a full-time Pharmacy Clinical Review Specialist I to support the Pharmacy Services department. 

The Specialist will oversee administrative and system processes that relate to pharmacy prior authorizations. They will manage the first line clinical review of prior authorization requests on behalf of physicians and UPMC Health Plan members and will collaborate with clinicians regarding supporting medical documentation in accordance with formulary guidelines. He/she will also manage the quality review of requested prior authorizations.

Responsibilities:

  • Provide excellent internal and external customer service maintaining a second request for information and customer complaint goal of zero.
  • Act as a conduit of information between the Pharmacy Service Representatives and the clinical staff
  • Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to the line of business.
  • Perform peer reviews of prior authorization requests.
  • Maintain or exceed designated quality and production standards.
  • 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.
  • Complete standard/expedited pharmacy coverage determinations according to departmental/government guidelines.
  • Report and respond to escalate issues and concerns within twenty-four hours.
  • 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.

Qualifications

  • HS diploma and pharmacy claims, pharmacy tech, and/or other related experience in a physician practice, ancillary provider, or other relevant healthcare setting required.
  • Competent in pharmacy claims process operating system.
  • Excellent knowledge of medical terminology, coordination of benefits, complaints and grievance guidelines, and prescription drug utilization management requirements.
  • Thorough knowledge of MS 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 the supervisor.


Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct