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Healthfirst Clinical Pharmacist - Prior Authorization Reviews in New York, New York

The Clinical Pharmacist is a dynamic position responsible for the review of prior authorization requests for medications requested under the medical benefit. Additionally, the Clinical Pharmacist will be responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly report for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine. The Clinical Pharmacist will work directly with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions. This position reports to the Sr. Pharmacy Manager

Duties & Responsibilities:

  • Monitor and review prior authorization requests for medications

  • Calculate appropriate billable units based on dosing based, indication, weight, BMI and other clinical considerations

  • Develop clinical criteria and medical policies for the review of medications

  • Ensure all clinical criteria is in compliance with Center of Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH)

  • Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews

  • Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH

  • Review monthly reports and provide feedback on trends, ideas for efficiency, and innovation

  • Ability to work well in a team environment and be a team player

  • Additional duties as assigned

Minimum Qualifications:

  • Pharmacy degree from an accredited school of pharmacy

  • Registered Pharmacist in the state of New York with a license in good standing.

  • Minimum of 1 year experience conducting prior authorization reviews

  • Strong clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews

  • Strong clinical writing and verbal skills

  • Demonstrated critical thinking and problem-solving skills.

  • Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits

  • Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities

Preferred Qualifications:

  • PGY1 Managed Care Residency (optional)

  • Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations.

  • Ability to lead large and small working meetings.

  • PC Skills with Microsoft Outlook, Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables).

License or Certification: Licensed pharmacist in the state of NY in good standing.

Regulatory or Compliance activities:

Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement (http://www.dol.gov/agencies/ofccp/posters)

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

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