Location : Remote : GA, TX, IN, KS, NJ. AZ. NC, PA license preferred,
SHIFT : 12-8 : 30pm Est M-F with rotating weekends, typing test will be required with interview.
Description
Position Purpose : Provide timely drug therapy for Medicaid health plan members by processing prior authorization and medical necessity requests
- Direct resources to individual cases, projects, or critical needs.
- Update health plan pharmacy documentation in conjunction with state laws.
- Maintain relationships with all client health plan pharmacy leadership regarding escalated claims
- Implement, maintain and provide training on all departmental process and procedural documents, including prior authorizations
- Manage prior authorization requests and pharmacists' determinations for drug products according to member benefits and coverage criteri
- Provide clinical guidance and support to the assigned pharmacists and pharmacy technicians
- Responsible for setting criteria for medication analysis, coordinate reports to clients, meet regulatory reporting requirements for drug utilization review and fraud and abuse reporting
- Develop clinical criteria for review of non-formulary or non-preferred drug lists medications and communicate recommendations to clients
- Oversee the drug utilization review and medication therapy management programs at the assigned plan to meet Medicare Part D requirements and develop systematic reviews of prescription claims to meet strategic initiatives
- Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practices
- Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Qualifications
Education / Experience : Bachelor's degree or advanced degree (PharmD., M.S) in pharmacy. 3+ years of retail or hospital pharmacy experience or 1+ years of managed care pharmacy experience .
Clinical pharmacy experience in managed healthcare preferred.
License / Certification : Current state's Pharmacist license with no restrictions. Additional license may be required as need by state or contract.
- Pa review, GA, TX, IN, KS, NJ. AZ. NC, PA license preferred, 12-8 : 30pm est shift M-F with ortating weekends, typing test with interview, interviewee must be on a pc
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