Healthfirst

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.

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
• 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 provide feedback on trends, ideas for efficiency, and innovation
• 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 with a state license in good standing.
• Work experience conducting prior authorization reviews
• Clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews
• Work experience requiring written and verbal clinical communication that is clear, concise, grammatically correct, and professional
• Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits

Preferred Qualifications: 

• PGY1 Managed Care Residency
• Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations
• Demonstrated critical thinking and problem-solving skills
• Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities
• Experience leading 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 good standing

Regulatory or Compliance activities: 

Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $100,900 - $145,775

• All Other Locations (within approved locations): $86,500 - $128,690

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.