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Independent Health Association, Inc. Clinical Pharmacist Reviewer in Williamsville, New York

\*New hires must be fully vaccinated against the COVID-19 virus by the date of hire, unless granted an accommodation for a qualified medical or religious vaccine exemption.
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Overview

The Clinical Pharmacist Reviewer shall be responsible to research initial coverage determinations, coordinate clinical peer review, prepare written responses to appeals, and provide member education in accordance with regulatory standards and member benefit contract. In addition, the Clinical Pharmacist Reviewer will review and make decisions on contractual pharmacy appeal cases.
Qualifications
Licensed to practice pharmacy in New York State required (registered pharmacist degree); Bachelors of Science in PharmD preferred.
Four (4) years of clinical experience required; Utilization Management experience preferred.
Comprehensive knowledge and experience with managed care benefit plans.
Demonstrated ability in researching and assisting clinical team in rendering coverage determinations in accordance with member contract and policy.
Excellent communication verbal, written and interpersonal communication skills required.
Demonstrated ability to handle escalated calls and to clearly and articulately deliver messages regarding decisions.
Solid PC and navigational skills required. Knowledge of Siebel, Aerial and Claims is a plus.
Possess initiative and solid, logical thinking capabilities.
Proven ability to manage multiple, time-sensitive priorities and adherence to all deadlines, while remaining organized.
Ability to work a flexible schedule required.
Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.
Key Accountabilities

A. Research
Thoroughly investigate clinical appeals, utilizing appropriate internal and external resources to ensure coverage determinations are consistent and within member benefit contract. Investigate and research all levels of contractual complaints/appeals independently to ensure decisions are within accordance of applicable policies, procedures and contracts. Responsible for completing special projects when assigned.

B. Accountability
Responsible for ensuring verbal and written response to appeals and regulatory investigations are in compliance with regulatory standards. Responsible for providing member education/outreach related to coverage determinations and member benefit contract.

C. Coordination
Coordinate and oversee the clinical peer review of appeals and assist the clinical team in rendering consistent coverage determinations in accordance with policy and member benefit contract.

D. Reporting
Thorough and accurate completion of log worksheet to maintain consistency in logging complaints/appeals. Responsible for maintaining and monitoring outstanding case logs to plan and prioritize workload. Responsible to identify appeal trends and process improvements where applicable.

E. Continuous Improvement
Based on measurement and evaluation of clinical appeal data, assist in continuously developing systems, workflows and coverage criteria to better meet the needs of the customer.

F. Departmental Support
Responsible for assisting in meeting department goals and objectives and identifying process improvements to continuously improve member/provider satisfaction. Attend assigned meetings as department representative and report to team members when necessary.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant's race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. for additional EEO/AAP or Reasonable Accommodation information.

Current Associates must apply internally via their Career Worklet.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here: https://www.independenthealth.com/AboutIndependentHealth/Careers/AdditionalEEO-AAPInformation for additional EEO/AAP or Reasonable Accommodation information.

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