Anticipated End Date:

2024-10-25

Position Title:

Pharmacist Clinical- Prior Authorization

Job Description:

Pharmacist Clinical- Prior Authorization (Pharmacist Clinical)

Location: Virtual with the ideal candidate living within 50 miles of one of our Elevance Health PulsePoint locations.

The Pharmacist Clinical is responsible for managing the selection and utilization of pharmaceuticals and supports core clinical programs such as DUR, DIS and formulary management.

How you will make an impact:

• Researches and synthesizes detailed clinical data related to pharmaceuticals.
• May review and approve or deny coverage for pharmaceuticals (as permitted by state/federal law or state/federal program contracts) based on medical necessity criteria, and coordinates with Elevance Health or health plan medical directors as needed.
• Serves as a clinical resource to other pharmacists on areas such as prospective, inpatient and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions.
• Make prior authorization determinations, research, and synthesize detailed clinical data related to injectable pharmaceuticals.
• Coordinates with Medical Directors and RNs in the UM Department, Providers.
• Provides evaluation of memberRx needs and therapies through review of medication history to determine if medications are appropriate.
• Provides injectable drug medical necessity reviews covered under the Medical benefit (Part B).
• Determines potential barriers to compliance and identifies solutions to overcome barriers.
• Adhere to all Medicare, policy, and procedures.
• Ensures that providers understand appropriate use of current prescriptions.
• Reviews medication requests with physicians and/or physician representatives when therapies do not need national standards.
• Serves as a resource to the clinical team in disease management and other clinical areas.

Minimum 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.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed/Registered Pharmacist

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

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.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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 [email protected] for assistance.