Managed Care Clinical Pharmacist
7 days ago
At St. Luke's, we pride ourselves on fostering a workplace culture that values diversity, promotes collaboration, and prioritizes employee well-being. Our commitment to excellence in patient care extends to creating an environment where our team can thrive both personally and professionally. With opportunities for growth, competitive benefits, and a supportive community of colleagues, St. Luke's is truly a great place to work.
We are seeking a Managed Care Clinical Pharmacist to join our St. Luke's Health Plan Pharmacy Benefits team.
The Managed Care Clinical Pharmacist supports the prior authorization (PA) and formulary management needs of the St. Luke's Health Plan Pharmacy Benefits team. In this position, you will ensure accuracy and integrity of claims adjudication, prior authorization requests, and member determination communications, as well as perform, coordinate, and administer prior authorization appeals for specialty and high-impact medications requiring clinical management.
What You Can Expect
- Utilizes broad understanding of pharmacy, managed care, PBM, market and regulatory insights to assist in the development of pharmacy formulary and drug strategies to mitigate costs and trends, while improving members' health outcomes and costs.
- Monitors new drugs to market, performing cost and clinical analysis to apply appropriate drug statuses to formularies while minimizing member disruption.
Reviews prior authorization appeals to approve or deny coverage for medications based on medical necessity criteria. Coordinates with pharmacy appeals committee and Health Plan medical directors as needed.
Provides clinical support in working both internally and across departmental teams (clinical, medical benefit, customer service, sales/marketing, operations, contracting/rebates, analytics) in assuring successful performance of pharmacy programs. Provides support to the Pharmacy Benefits tier desk team regarding clinical questions, prior authorization oversight, claims adjudication resolution, and member customer service.
Employs the use of software platforms to ensure accuracy and integrity of prior authorization request forms, member communications, and claims adjudication. Assists with reporting, audits, and analytics to demonstrate PA clinical, financial, and operational effectiveness and quality. - Communicates with external stakeholders as it pertains to the PA process, answering in a timely, accurate, and professional manner.
- Assist with plan design and implementation of new insurance products.
Performs other duties as assigned.
- Degree from an accredited pharmacy program
- One (1) year of relevant experience (MBA or Pharmacy Residency in lieu of experience)
- Valid Idaho pharmacist license
- Experience working in Managed Care
Why St. Luke's
At St. Luke's, caring for people in the communities we serve is our mission - and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Personify Health Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.
St. Luke's is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.
*Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.
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