Part-time Managed Care Pharmacist Authorization Reviewer - Remote

5 Vacancy
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Offer Salary

$ 60 - $ 70 /hourly

Job Description

We are currently hiring a Part-time Managed Care Pharmacist Authorization Reviewer! If you have managed care pharmacy benefit experience, advanced knowledge of medication therapy clinical appropriateness, hold an unrestricted Oregon Pharmacist licensure, and value being part of a team that makes a difference, you may be the right person for the position! Apply today!

JOB PURPOSE: Managed Care Pharmacist, Authorization Review

This position is responsible for reviewing pharmacy claims and processing pharmacy prior authorizations. By demonstrating consistent application of knowledge and skills, they will support the delivery of appropriate, safe, efficient, and cost-effective pharmacy services as part of a multidisciplinary team and play a key role in supporting and incorporating principles of population-based medicine.

QUALIFICATIONS, EDUCATION, and EXPERIENCE

Unrestricted clinical licensure as a pharmacist in the state of Oregon
Bachelor’s Degree in Pharmacy required; Doctor of Pharmacy preferred
Managed Care residency or experience preferred
Three to five years of clinical practice or experience working in a healthcare organization preferred

ESSENTIAL RESPONSIBILITIES: Managed Care Pharmacist and Pharmacy Benefit Coordination

Maintain working knowledge related to members enrolled in the Oregon Health Plan (OHP)
Work with Utilization Management Team including Chief Medical Officer, MD Reviewer, Manager of Medical Services, and other staff as appropriate, to ensure that authorizations are processed according to organizational, and State required guidelines
Render clinical decisions based on Oregon Administrative Rules, Line Finder (prioritized list), prior authorization criteria, and Advanced Health’s current formulary
Act as a liaison with pharmacy providers, medical providers, and third-party administrators (Pharmacy Benefit Administrator [PBM]) to ensure efficient processing of data and claims
Manage the processing of all pharmacy claims through a PBM in a timely manner
Analyze claims for appropriateness of services and interprets benefits in accordance with established contracts
Follow all processes and procedures for consistent output of pharmacy authorization determinations
Assist in identifying providers with practice patterns which are not in conformity to best practice standards
Participate in quality and organizational process improvement activities and teams when requested
Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
Handle confidential information and materials appropriately and maintains a secure work area
Other duties as assigned

ESSENTIAL RESPONSIBILITIES: ORGANIZATIONAL TEAM MEMBER

Participate in quality and organizational process improvement activities and teams when requested
Support and contribute to effective safety, quality, and risk management efforts by adhering to established; policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations
Recognize new developments and remain current in [position’s expertise] best practice standards and anticipate organizational modifications
Advance personal knowledge base by pursuing continuing education to enhance professional competence
Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
Represent organization at meetings and conferences as applicable

KNOWLEDGE, SKILLS, and ABILITIES

Advanced knowledge of major medication therapy, drug-drug interactions, and disease states
Advanced ability to evaluate clinical appropriateness of medication therapy
Knowledge of managed care concepts, principles, and operations
Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
Excellent skills in problem anticipation, problem solving, and analytical thinking
Critical thinking skills in using logic and reasoning to identify strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
Sensitivity to and supportive of the various missions and purposes of community partners such as education, clinical care and community service and benefit
Interpersonal strengths in influencing effective group processes, able to work with internal and external stakeholders of various position levels and responsibilities, including physicians and other health care professionals
Ability to manage, plan, and adjust work schedule to meet work responsibilities and objectives, report to work as scheduled, and work a flexible schedule when needed
Ability to effectively present information and respond to questions from coworkers, supervisor, and customers
Ability to work with mathematical concepts such as probability and statistical inference
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations
Must be adept at using various applications including database, spreadsheet, word processing, and transactional system software
Ability to interpret and extensive variety of technical instruction in mathematical or diagram form and deal with several abstract and concrete variables
Understanding complex medical and behavioral health diagnostic information to assist providers and other care coordinators in treatment planning
Proficient in Microsoft Office Suite and Windows Operating System (OS)
Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission
Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
Excellent people skills and friendly demeanor
Attention to detail and organization skills
Ability to handle stress and sensitive situations effectively while projecting a professional attitude
Ability to communicate professionally, both conversing and written
Ability to work with diverse populations and interact with people of differing personalities and backgrounds
Sensitive to economic considerations, human needs and aware of how one’s actions may affect others
Ability to organize and work in a sensitive manner with people from other cultures
Poised; maintains composure and sense of purpose

WORKING CONDITIONS

This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.

Work Condition:

Employee generally works within a remote work from home environment.
Travel may be required on occasion.
Hours of operations and specific staff scheduling may vary based on operational need.

Exposed to: Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.

Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery or software, such as fax, copier, calculator, multi-line telephone system, or scanner.

May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.

Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task.

This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of DOCS Management Services employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice