Clinical UM Pharmacist

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

• 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

• 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)

medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions