Clinical UM Pharmacist
HealthFirst
Summary
The Clinical UM Pharmacist is a dynamic position responsible for the review of prior authorizations for medications requested under the medical benefit. Additionally, the Clinical UM Pharmacist is responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly report for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine. The Clinical Pharmacist works directly with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions.
Job description
Duties & Responsibilities
- Monitor and review prior authorization requests for medications
- Calculate appropriate billable units based on dosing, indication, weight, BMI and other clinical considerations
- Develop clinical criteria and medical policies for the review of medications
- Ensure all clinical criteria is in compliance with Center of Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH)
- Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
- Perform and present drug utilization reviews (DUR) on medical benefit medications to assess clinical appropriateness, safety, and cost-effectiveness
- Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH
- Work across departments as needed to complete Utilization Management reviews
- Review monthly reports and present on trends, ideas for efficiency/innovation, and medical spend
- Ability to work well in a team environment and be a team player
- Additional duties as assigned or required
Minimum Qualifications
- Pharmacy degree from an accredited school of pharmacy
- Registered Pharmacist in the state of New York with a license in good standing
- Minimum of 1 year experience conducting prior authorization reviews
- Strong clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews
- Strong clinical writing and verbal skills
- Demonstrated critical thinking and problem-solving skills
- Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits
- Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities
Preferred Qualifications
- PGY1 Managed Care Residency (optional)
- Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations
- Ability to lead large and small working meetings
- PC Skills with Microsoft Outlook, Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables)
License or Certification
Licensed pharmacist in the state of NY in good standing.
Regulatory or Compliance activities
Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.
Requirements
- Pharmacy degree from an accredited school of pharmacy
- Registered Pharmacist in the state of New York with a license in good standing
- Minimum of 1 year experience conducting prior authorization reviews
- Strong clinical knowledge of pharmaceuticals and disease states
- Strong clinical writing and verbal skills
- Demonstrated critical thinking and problem-solving skills
- Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits
- PGY1 Managed Care Residency (optional)
- Knowledge of CMS regulations including National and Local Coverage Determinations
- Ability to lead large and small working meetings
- PC Skills with Microsoft Outlook, Word, PowerPoint, and Excel (Pivot tables)
Benefits
- Medical, Dental & Vision
- Incentive Programs
- Recognition Programs
- Life Insurance
- 401(k) Contributions
Company overview
HealthFirst is a medical equipment manufacturing company specializing in the development and production of healthcare devices and diagnostic equipment. As a medical device manufacturer, the company focuses on creating innovative solutions that enhance patient care and improve clinical outcomes. HealthFirst operates in the competitive medical technology sector, where it likely develops products ranging from diagnostic instruments to therapeutic devices used in various healthcare settings. The company's commitment to quality and regulatory compliance positions it as a reliable provider of medical equipment to hospitals, clinics, and healthcare facilities. With expertise in medical device engineering and manufacturing, HealthFirst contributes to advancing healthcare technology while maintaining rigorous standards for safety and efficacy. The company's products are designed to meet the evolving needs of healthcare professionals and patients, supporting improved diagnosis, treatment, and monitoring of medical conditions across different therapeutic areas.