Pharmacist | Prior Authorization Pharmacy Manager

Job Description

Job Summary:

• The Prior Authorization Pharmacist is responsible for rendering decisions for prior authorization requests utilizing clinical judgement and internal criteria.
• The Pharmacist is also responsible for improving patient care through medication reconciliation, counseling and care management.

Duties & Responsibilities:

• Reviews Medical drug prior authorization and appeal requests for all LOBs then renders coverage determinations based on preferred drug strategies, available benefits, internal criteria and clinical judgement
• Assists in responding to internal/external inquiries related to prior authorization review including weekends and holidays.
• Assists in identifying inappropriate utilization during claims and prior authorization review.
• Performs audits as necessary of vendor or internal reviewed cases to ensure all clinical, organizational and operational standards have been met.
• Completes medication reviews for members to ensure safe and efficacious therapy.
• Assists in organizational and departmental quality improvement initiatives.
• Responds to pharmacy benefit related inquiries.
• Participates in Quarterly Pharmacy and Therapeutics (P&T) meetings.
• Creates and reviews prior authorization criteria for medications as needed.

Required Education:

• Doctor of Pharmacy required.
• Clinical pharmacy experience and utilization management experience in a managed care environment preferred.
• Experience in Pharmacy management of government programs (Medicaid and Exchange) preferred.
• Proficiency with MS Word, Excel, and PowerPoint is required. Experience in the evaluation and interpretation of pharmacy claims data and other clinical data is preferred.
• Position requires excellent organizational, teamwork, interpersonal, time management, written and verbal communication skills.

Licensure & Certification Required:

• Current New York State Pharmacy License (active and not limited).

Professional Competencies:

• Integrity and Trust.
• Customer Focus.
• Functional/Technical Skills.
• Written/Oral Communications.