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Clinical Pharmacist
1 month ago
We are seeking a highly skilled Clinical Pharmacist to join our team as a Prior Authorization Specialist. In this role, you will be responsible for managing the selection and utilization of pharmaceuticals, supporting core clinical programs such as DUR, DIS, and formulary management.
Key Responsibilities:
Research and synthesize detailed clinical data related to pharmaceuticals.
Review and approve or deny coverage for pharmaceuticals based on medical necessity criteria, and coordinate with Elevance Health or health plan medical directors as needed.
Serve as a clinical resource to other pharmacists on areas such as prospective, inpatient, and retrospective DURs, and provide dosage conversion and clinical support for therapeutic interventions.
Make prior authorization determinations, research, and synthesize detailed clinical data related to injectable pharmaceuticals.
Coordinate with Medical Directors and RNs in the UM Department, Providers.
Provide evaluation of memberRx needs and therapies through review of medication history to determine if medications are appropriate.
Provide injectable drug medical necessity reviews covered under the Medical benefit (Part B).
Determine potential barriers to compliance and identify solutions to overcome barriers.
Adhere to all Medicare, policy, and procedures.
Ensure that providers understand appropriate use of current prescriptions.
Reviews medication requests with physicians and/or physician representatives when therapies do not need national standards.
Serve as a resource to the clinical team in disease management and other clinical areas.
Requirements:
Requires BA/BS in Pharmacy.
Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background.
Requires a registered pharmacist.
Must possess an active unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh).
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel, or any embassy located in or outside of the US, unless they are command-sanctioned activities.
Preferred Skills, Capabilities, and Experiences:
PharmD preferred.
Experience in Injectable/Specialty Drug oversight including Drug Utilization management preferred.
Experience with direct patient counseling, provider interaction, and/or education preferred.
Understanding of the Specialty Drug market preferred.
Clinical knowledge of Biotech/Oncology drug preferred.
Part B experience strongly preferred.
Excellent PC and Microsoft Office (Word, Outlook, Excel) skills preferred.
Clinical Pharmacy Experience strongly preferred.
About Elevance Health:
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs, and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state, and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.
