Clinical UM Pharmacist

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 & ResponsibilitiesMonitor and review prior authorization requests for medicationsCalculate appropriate billable units based on dosing, indication, weight, BMI and other clinical considerationsDevelop clinical criteria and medical policies for the review of medicationsEnsure 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 reviewsPerform and present drug utilization reviews (DUR) on medical benefit medications to assess clinical appropriateness, safety, and cost-effectivenessEnsure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOHWork across departments as needed to complete Utilization Management reviews Review monthly reports and present on trends, ideas for efficiency/innovation, and medical spendAbility to work well in a team environment and be a team playerAdditional duties as assigned or requiredMinimum QualificationsPharmacy degree from an accredited school of pharmacyRegistered Pharmacist with a state license in good standing.Work experience conducting prior authorization reviewsClinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviewsWork experience requiring written and verbal clinical communication that is clear, concise, grammatically correct, and professionalKnowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefitsPreferred QualificationsPGY1 Managed Care ResidencyKnowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage DeterminationsDemonstrated critical thinking and problem-solving skillsPassion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunitiesExperience leading large and small working meetingsPC Skills with Microsoft Outlook, Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables)Compliance & Regulatory Responsibilities: Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.License/Certification: Licensed pharmacist in good standingHiring Range*:Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430All Other Locations (within approved locations): $88,700 - $131,920As 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.