Pharmacist, Clinical Appeals

Summary of Job

Partner with G&A team to review pharmacy appeals, pharmacy benefit appeals, and related medical appeals, including process refinement, with responsibility for Level 1 and Level 2 appeals.  Coordinate analysis of appeals determination trends and quality measures with pharmacy benefits management (PBM) vendor and company-wide quality and compliance teams.  Partner with PBM vendor and with Pharmacy Performance team to support IRO preparation and responses.  Responsible for managing performance of staff and activities related to Pharmacy quality and compliance including but not limited to monitoring and trending of key performance indicators (KPIs) and compliance reports relative to safety reporting processes and regulatory authority submissions.  Provide active oversight and ongoing direction for the utilization management Pharmacy team and quality assurance process including case review, review with staff and monthly scoring.  Direct the management reporting on productivity, clinical quality, compliance with state and federal pharmacy requirements and timelines.  Lead, develop and enforce standards of quality, quality assurance, and monitoring for the utilization management function and staff.  Work with practitioners and formulary and vendor to update clinical decision trees, which will enhance the efficiency of the team.  

Responsibilities

• Manage the day-to-day functions of the Clinical Pharmacy quality assurance process for appeals.
   
• Direct and ensure Appeals queue management for timeliness and workforce modeling.
   
• Work collaboratively with health plan market leads to lead Plan-sponsored initiatives designed to assist and empower members in closing gaps.
   
• Analyze audit and inspection findings and suggest remediation as well as maintain overview of CAPA responses and resulting measures
   
• Track trends in quality reviews, drugs, costs and review with senior leadership.
   
• Exercise considerable latitude in determining objectives and approaches to strategy for the utilization management program’s success across the enterprise.
   
• Review high dollar reports (medical drugs exceeding 50k threshold for appropriateness and billable units).
   
• Develop, implement, and maintain UM appeals reporting, including appeals dashboard, practitioner scorecard, timeliness, denial language, and federal/state regulatory compliance. 
   
• Responsible for identifying training needs for staff (in-service) and developing and overseeing training to ensure awareness of and compliance with organizational objectives and applicable laws and regulatory requirements.
   
• Design, review and use plan tools, reports and system results to conduct weekly, monthly, and quarterly reviews with department staff. Maintain staff-specific scorecards to be shared monthly.
   
• Review requests for authorization for Medicare, NYS Medicaid, Commercial, and Exchange lines of business.
   
• Responsible for development and maintenance of Utilization Management Trees to improve efficiency of the staff.
   
• Participate in the Pharmacy & Therapeutic Committee to include Step-Protocol Review, Non-Formulary Review, Subcommittee Management (Meetings), Drug Reviews, and Updates.
   
• Support HCCI initiatives as necessary
   
• Contribute to the design and development of policies, procedures, and operating guidelines.
   
• Other duties/projects as assigned.