Pharmacist Clinical- Prior Authorization
Elevance Health

Job Info

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Pharmacist Clinical- Prior Authorization (Pharmacist Clinical)

Location: Virtual with the ideal candidate living within 50 miles of one of our Elevance Health PulsePoint locations.

The Pharmacist Clinical is responsible for managing the selection and utilization of pharmaceuticals and supports core clinical programs such as DUR, DIS and formulary management.

How you will make an impact:

• Researches and synthesizes detailed clinical data related to pharmaceuticals.
• May review and approve or deny coverage for pharmaceuticals (as permitted by state/federal law or state/federal program contracts) based on medical necessity criteria, and coordinates with Elevance Health or health plan medical directors as needed.
• Serves as a clinical resource to other pharmacists on areas such as prospective, inpatient and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions.
• Make prior authorization determinations, research, and synthesize detailed clinical data related to injectable pharmaceuticals.
• Coordinates with Medical Directors and RNs in the UM Department, Providers.
• Provides evaluation of memberRx needs and therapies through review of medication history to determine if medications are appropriate.
• Provides injectable drug medical necessity reviews covered under the Medical benefit (Part B).
• Determines potential barriers to compliance and identifies solutions to overcome barriers.
• Adhere to all Medicare, policy, and procedures.
• Ensures that providers understand appropriate use of current prescriptions.
• Reviews medication requests with physicians and/or physician representatives when therapies do not need national standards.
• Serves as a resource to the clinical team in disease management and other clinical areas.

Minimum Requirements:

• Requires BA/BS in Pharmacy.
• Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background.
• Requires a registered pharmacist.
• Must possess an active unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh).
• Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US, unless they are command-sanctioned activities.

Preferred Skills, Capabilities, and Experiences:

• PharmD preferred.
• Experience in Injectable/Specialty Drug oversight including Drug Utilization management preferred.
• Experience with direct patient counseling, provider interaction, and/or education preferred.
• Understanding of the Specialty Drug market preferred.
• Clinical knowledge of Biotech/Oncology drug preferred.
• Part B experience strongly preferred.
• Excellent PC and Microsoft Office (Word, Outlook, Excel) skills preferred.
• Clinical Pharmacy Experience strongly preferred.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

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