Pharmacist

• Responsible for support and input to clinical programs such as: Health Management, Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high quality, cost effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place
• Participate in the Coverage Determination (Certification, Prior Authorization, Medical Exception, Exception to Coverage, etc.) process by reviewing all requests which are not clearly approvable based on specified criteria (algorithms), making all coverage denial determinations, and identifying themselves by first name, title, and responsibility at Navitus in relation to drug utilization management program administration
• Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers
• Provide input to clinical content of new programs and for maintenance of existing programs
• Complete all annual URAC training requirements
• Facilitation of communication and education to clients, members, and internal staff regarding clinical daily issues and objectives
• Provide support to operational departments on the implementation of various PBM programs and daily functioning in support of member/patient quality of care
• Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee
• May review health care survey data for Medicare Part D qualified participants and/or perform phone consultations with Med-D enrollees; aid in documentation of calls; designate enrollees for repeat interaction
• Other duties as assigned

Pharmacist I – Clinical Prior Authorization

• Review and render decisions on authorizations and appeals for specialty, non-specialty, and physician administered drugs
• Conduct peer-to-peer calls with prescribers to discuss the clinical rationale of adverse determinations
• Participate in clinical quality audits and inter-rater reliability testing
• Provide internal team support for escalations and questions
• Apply clinical expertise to ensure appropriate and safe use of pharmaceuticals by members and providers.
• Compliance with all applicable laws and regulations
• Other duties as assigned

Prior Authorization Pharmacist

• Use Oscar and vendor tools to determine eligibility, screen for required documents, create, process, and properly track pharmacy prior authorization requests
• Prepare, organize, and distribute pharmacy prior authorization requests for review by pharmacist/physician and respond to pharmacist/physician requests for additional information
• Collect relevant medical information (via telephone, fax, and portal) and apply the appropriate PA criteria, clearly documenting all communication and decision making
• Meet required decision-making timeframes, including promptly triggering escalation for cases requiring pharmacist review
• Communicate oral and written prior authorization outcome notifications that comply with standards and requirements for content and accuracy
• Compliance with all applicable laws and regulations
• Other duties as assigned

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Pharmacist I – Clinical Prior Authorization

Prior Authorization Pharmacist

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