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The Pharmacist I, Clinical Prior Authorization will be responsible for: performing Prior Authorizations; perform duties related to Drug Utilization Review including concurrent, retrospective, and prospective components; and support Customer Care with clinical calls requiring pharmacist intervention. The Pharmacist I, Clinical Prior Authorization is also responsible for interfacing with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries’ benefits and therapeutic interventions, and reviewing/evaluating the health surveys and utilization data for program management and development.

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Responsibilities

How do I make an impact on my team?

Responsible for support and input to clinical programs such as: Health Management, Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high quality, cost effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place
Participate in the Coverage Determination (Certification, Prior Authorization, Medical Exception, Exception to Coverage, etc.) process be reviewing all requests which are not clearly approvable based on specified criteria (algorithms), making all coverage denial determinations, and identifying themselves by first name, title, and responsibility at Navitus in relation to drug utilization management program administration
Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers
Provide input to clinical content of new programs and for maintenance of existing programs
Complete all annual URAC training requirements
Facilitation of communication and education to clients, members, and internal staff regarding clinical daily issues and objectives
Provide support to operational departments on the implementation of various PBM programs and daily functioning in support of member/patient quality of care
Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee
May review health care survey data for Medicare Part D qualified participants and/or perform phone consultations with Med-D enrollees; aid in documentation of calls; designate enrollees for repeat interaction
Other duties as assigned

Qualifications

What our team expects from you?

A minimum of a bachelor’s degree in Pharmacy or Pharm D. Current, unrestricted licensure as a Registered Pharmacist in the state of residence, or the ability to gain reciprocity within 4 months, may be required based on state of residence laws or client contracts. Other State Pharmacy Licenses may be required as business need dictates. Must continually maintain education credits to maintain active licensure.
Two years’ work experience in a clinical setting, or clinical or managed care pharmacy practice residency preferred
Knowledge of PBM industry, formulary management, pharmacy claims and managed care principles and practices desired
Exceptional clinical skills and ability to apply sound clinical judgment to a variety of situations is necessary
Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline, Internet) preferred
Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences
Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
Requires attention to details to assure projects are clinically, editorially, and systems accurate and can be operationalized
Proficiency in MS Word, Excel, Power Point including tables, charts and figures preferred
Participate in, adhere to, and support compliance program objectives
The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

Top of the industry benefits for Health, Dental, and Vision insurance
20 days paid time off
4 weeks paid parental leave
9 paid holidays
401K company match of up to 5% - No vesting requirement
Adoption Assistance Program
Flexible Spending Account
Educational Assistance Plan and Professional Membership assistance
Referral Bonus Program – up to $750!

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Navitus Health Solutions is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, creed, sex, pregnancy, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by law.

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Pharmacist I, Clinical Prior Authorization

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