Pharmacist, Prior Authorization & Appeals

Summary of Job

Provide active oversight and ongoing direction for the utilization management of Pharmacy vendors and quality assurance process including case review, review with staff and monthly scoring. Evaluate and advise Medical Directors on clinical criteria and appeals. Provide reporting on appeals, UM case review, clinical quality, compliance with state and federal pharmacy requirements and timelines. Develop and enforce standards of quality, quality assurance, and monitoring for the utilization management function and staff. Work with providers to make clinical decision trees to enhance the efficiency of the team.

Responsibilities:

• Manage the day-to-day review of clinical Pharmacy cases and appeals.
• Work collaboratively with health plan market leads to lead Plan-sponsored initiatives designed to assist and empower members in closing gaps.
• Manage effective corrective action and preventive actions (CAPA) process including the tracking, trend analysis, root cause analysis, and implementation of process improvement measures.
• Analyze audit and inspection findings and suggest remediation as well as maintain overview of CAPA responses and resulting measures.
• Exercise considerable latitude in determining objectives and approaches to strategy for Pharmacy’s utilization management program’s success.
• Provide delegate oversight for EmblemHealth’s Pharmacy Benefit Manager.
• Review case authorizations for Medicare, NYS Medicaid, Commercial, and Exchange lines of business.
• Review high dollar report (medical drugs exceeding 50k threshold for appropriateness and billable units).
• Respond to email inquiries from Grievance and appeals, medical directors, and provide interdepartmental support.
• Review high dollar report (medical drugs exceeding 50k threshold for appropriateness and billable units).
• Respond to email inquiries from Grievance and appeals, medical directors, and provide interdepartmental support.
• Meet with PBM on case review findings.
• Implement UM reporting, including: UM dashboard, practitioner scorecard, timeliness, denial language, and federal/state regulatory compliance.
• Design, review and use plan tools, reports and system results to conduct weekly, monthly, and quarterly reviews with department staff.
• Participate in the Pharmacy & Therapeutic Committee to include: Step-Protocol Review, Non-Formulary Review, Subcommittee Management (Meetings/minutes), Drug Reviews, and Updates.
• Contribute to the design and development of policies, procedures, and operating guidelines.
• Perform other duties/projects as directed, assigned, or required.