Clinical Pharmacist Advisor - Med D Prior Auth

The clinical pharmacist is an operation based role that conducts clinical reviews of medical data collected to perform prior authorization for specialty medications. The clinical pharmacist will apply clinical knowledge to plan approved criteria for prospective and concurrent reviews of cases. This role will work for supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations.
 
Responsibilities:

• Ensure accuracy of case setup and clinical review of Medicare appeals cases.
• Review internal notes or fax requests thoroughly for pertinent information.
• Provide clear, concise, and accurate documentation for case reviews.
• Contacting providers, if needed, for clinical information to decision cases
• Utilize work instructions and Medicare guidelines for accurate case processing.
• Comply with CMS mandated timelines and department productivity and quality standards.
• Acquire and utilize clinical judgement and knowledge, drug compendia resources, relevant and changing work instructions, and CMS Medicare guidance.
• Collaborates with the CRU Technician to process referrals, including answering clinical questions, collecting appropriate clinical/ medical data needed to perform clinical assessments, and reviews as per the health plan/employer agreed criteria within the designated service level agreements.
• Coordinates timely communication of case decision to physician, health-plan/employer, patient and other healthcare professionals following agreed upon approval & denial management processes.
• Handles inbound phone calls and escalations from physicians or patients regarding Prior Authorization
• Establishes and maintains communication among, health plan and employer group staff.
• Maintain professional and technical knowledge of drug and disease-states for the Specialty Pharmacy programs administered within the Case Review Unit.
• Performs other related projects and duties as assigned including on call and after hours pharmacist availability could be required.

• Prior authorization experience preferred.
• Medicare Part D experience required
• Previous pharmacy experience in retail or hospital preferred.
• Minimum 1 year of experience although 2-5 years is preferred.

• Prior Authorization
• Medicare Part D

• Bachelor's Degree Required, Pharm D Preferred.