PHH Peak Health Holdings is hiring a Clinical Utilization Management Pharmacist to perform drug utilization reviews for initial determinations and appeals across various lines of business. In this role, you will serve as a key subject matter expert and ensure the timely execution of reviews in compliance with all applicable standards.
What You'll Do
- Make prior authorization and step therapy determinations for drug utilization reviews based upon clinical evidence for all lines of business.
- Participate in the appeals process for drug reviews for all lines of business.
- Own the operational execution of the drug utilization review process.
- Serve as an inter-departmental subject matter expert for utilization management as it relates to drug reviews.
- Work with the Manager of Clinical Pharmacy to ensure timely execution of all drug reviews in compliance with accreditation and regulatory standards.
- Work with the Manager of Clinical Pharmacy and Medical Directors to identify review trends and policy needs.
- Work with the Manager of Clinical Pharmacy and Director of Clinical and Technical Integration to identify and escalate operational and technical issues.
- Assist with internal and operational policy needs as they relate to drug utilization management review.
- Work with the Manager of Clinical Pharmacy to resolve questions and disputes from clients and participating providers regarding drug review determinations.
- Work with Medical Directors and formulary team to review and make recommendations on specialty drugs requiring a specialty consult.
- Assist in monthly analysis of claims data to assess effectiveness of current formulary and utilization management strategies.
- Serve as a clinical pharmacy preceptor for residents and rotational pharmacy students as needed.
- Assist in creation of training materials for utilization management operational processes as needed.
- Assist in creation of clinical development tools for education as it relates to utilization review decision making as needed.
What We're Looking For
- Must possess current and unrestricted license to practice pharmacy issued by state of residence.
- Three (3) years of experience as a pharmacist in a clinical setting.
- Two (2) years of managed care experience.
Nice to Have
- Specific knowledge of CMS regulations, HIPAA and regulatory environment.
Technical Stack
- Microsoft Office applications (Excel and Access)
Team & Environment
You will report to the Manager of Clinical Pharmacy. You’ll collaborate closely with Medical Directors, the Clinical Formulary team, and the Director of Clinical and Technical Integration.
Work Mode
This position is onsite.
