Manager, Clinical Pharmacist UM

Description and Requirements

The Manager, Clinical Pharmacist UM is responsible for the review of prior authorization requests for medications requested under the medical benefit. Additionally, the role is responsible for the hands-on leadership over the UM Pharmacy team and all related people management responsibilities. This will be a Hybrid position that will need to report into 100 Church Street.

Job Description

Duties and Responsibilities:

• Responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly reports for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine.
• Work with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions Supervises, evaluates, and coordinates daily team operations and responsibilities to ensure that departmental productivity goals are met regarding quality, timeliness, accuracy, and consistency.
• Allocates, monitors, and controls resources while delegating and monitoring workloads.
• Assists Director of Specialty Pharmacy Programs with reviewing team performance. Implements and supports continuous process improvement and quality initiatives.
• Exercises judgment within defined procedures and policies to determine appropriate actions and administers departmental policies.
• Develops and monitors team goals; provides ongoing feedback and coaching; conducts annual performance reviews; leads by example; and ensures an atmosphere of open communication, teamwork, and empowerment to make informed decisions.
• Assists Director of Specialty Pharmacy Programs in directing, training, and developing team members by embodying the Trailblazer mindset and leading others by example.
• Builds and develops relevant business relationships, critically thinks about departmental problems, and makes informed recommendations as to how to resolve issues.
• Attend, schedule, and present in internal and external departmental meetings. Participates in preparation and conducting of regulatory site surveys [NYS Department of Health, Centers for Medicare and Medicaid Services (CMS), Dept of Insurance].
• Perform prior authorization reviews as set forth by CMS and/or NYSDOH. Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH.
• duties as assigned. 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 follows 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.
• Review monthly reports and provide feedback on trends, ideas for efficiency, and innovation.
• Ability to work weekends, holidays, and as needed to support departmental needs.
• Additional duties assigned