Analyst, Medical Pharmacy Policy

Description and Requirements

The Analyst, Medical Pharmacy Policy is responsible for implementing clinical criteria used to review prior authorizations for high-cost drugs on prior authorization platform. The role supports several organizational governance committees, assists the Healthfirst medical pharmacy leadership with meeting invitations for committee meetings, documenting meeting minutes and ratification of medical policies. The position plays a key role in the development of new processes related to these committees and medical policy oversight, maintaining regulatory compliance within the medical pharmacy policy department.

Duties & Responsibilities:

• Supports leadership with reviews and updates of medical policies
• Responsible for clinical criteria configuration on prior authorization platform and translation of clinical intent into operationally usable criteria
• Support the Healthfirst Pharmacy Advisory (HFPAC), Medical Policy (MP) and Clinical Utilization Management (UM) Governance Committee Chairs, committee members, and related workgroups by organizing all meeting materials (e.g. meeting minutes, presentations, etc.), tracking follow-up activities, and preparing/maintaining related reports and documentation
• Performs editorial formatting and review of policies
• Collaborate with the Regulatory, Compliance, Legal and Clinical departments to ensure deliverables adhere to local, state, federal, and Healthfirst-specific compliance and regulatory guidelines
• Comply with HIPAA requirements and maintain Protected Health Information (PHI) confidentiality of member, provider, medical and departmental information.
• Additional duties as necessary

• High School Diploma or GED from an accredited institution
• At least 2 years of work experience using and interpreting medical terminology and concepts
• Knowledge of specialty pharmaceuticals
• At least 1 year of work experience requiring strong analytical and logic skills applied to clinical criteria, ability to configure criteria logic, pathways, and decision points accurately
• Experience with Clinical guidelines including but not limited to Milliman Care Guidelines, Hayes Clinical Guidelines, EMEDNY, CMS National and Local Coverage Determinations
• Work experience requiring strong verbal and effective written communications while demonstrating exceptional grammar and spelling skills

• Associate degree from an accredited institution
• Certificate in Computer Application (CCA) or Diploma in Computer Application (DCA)
• Nationally certified Pharmacy Technician in good standing (i.e., PTCB, NHA)
• Project Management Professional Certificate
• Previous regulatory/compliance experience within a managed care environment
• Experience working in a fast-paced environment that requires flexibility and adapting to change while managing multiple priorities simultaneously
• Experience presenting and communicating to cross-functional groups within an organization
• Demonstrated problem-solving, initiative taking, multitasking and critical thinking skills
• Experience with MS Office Suite, MS Teams, MS Outlook, SharePoint and Adobe Acrobat.

• Ensure all medical policy activities are conducted in compliance with regulations.