Prior Authorization (PA) Pharmacist ID-1613
Curative is reimagining health insurance - with $0 out of pocket costs and by reducing barriers to people seeking care. Help us create a better healthcare experience for our members by making it easy and intuitive for them to access the care they need. We believe in a clear, simple health plan that allows our members to get zero-cost in-
network care anytime they need it. We want to put healthcare back in the hands of the patient and clinicians, with a focus on preventative care. Curative is rapidly growing and is raising the bar in what people expect from their health plan.
While this role's focus is primarily prior authorizations and appeals, the pharmacist will also assist with formulary management, P&T committee, commercial benefit design, data integration, and support disease management initiatives such as diabetes and adherence. As Curative continues to have rapid growth, our business needs can change as we grow together.
This is a REMOTE Position with Licensure required in the state of Texas.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Performs Prior Authorization reviews and coverage determinations as defined by pharmacy benefit design and established clinical treatment guidelines
- Manages all level of clinical review from Adverse Determination, Appeals and IRO.
- Support and manage health plan operations and ensures PBM aligns with benefit design
- Write, review, and update PA guidelines for support of P&T committee and pharmacy benefit design
- Acts as support to pharmacy technician and provides training and education where needed
- Meets assigned metrics and TAT as defined by regulatory requirements within state or lines of business
- Supports Disease Management initiative such as Adherence, Weight management, and Diabetes
- Collaborate with Medical Directors and other interdepartmental staff to communicate pharmacy strategies and clinical programs or initiatives
- Develops applicable desktop procedures for supporting PA applications
- Reviews and resolves complaints made by members and providers regarding Prior Authorization, formulary or pharmacy services
- Participates in support of the Pharmacy and Therapeutics Meeting to review and keep current on the drug formulary
- Performs appropriate literature and clinical research
- Knowledge of utilizing LexiComp, Facts and Comparisons, Micromedex, UptoDate, National guidelines, NCCN etc.
- Collaborate to create clear communication to members and/or providers on prior authorization determinations
- Work in partnership with pharmacy staff to assist in the implementation of utilization management programs
- Works in collaboration with Program Manager to help with workflows and operational efficiencies
- Evaluate opportunities for operational or process improvements
- Participate in Interdisciplinary Team (IDT) by identifying and presenting high risk cases
- Support and manage other related health plan operations
- Work adhering to US regulatory and Quality System requirements (21 CFR 820, etc.).
- This position assumes and performs other duties as assigned.
- Work hours Mon-Friday and some Saturdays.
QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions:
Required
- Possess strong analytical skills and detail oriented
- Ability to work independently with minimal supervision
- Understanding of claims processing and claims edits
- Intermediate level proficiency with MS Office applications- Word, Power Point, Excel, and Access
- Intermediate to advanced pharmacy drug recognition
- Ability to work in a dynamic and fast-paced environment
- 2 years of experience with specialty medications or prior authorization
- 1 year of experience with PBM or Managed Care setting
Preferred Qualifications
- 3 years as practicing pharmacist or 1 year as PGY-1 resident
- 2 years' experience in a Managed Care Setting
- Knowledge of Medispan or First Data Bank and drug classification system
- Understanding of Drug-Cost Analysis
- BCPS or CSP certification
EDUCATION and/or EXPERIENCE
- Doctor of Pharmacy (Pharm D) degree.
- Current Licensure in the state of Texas
CERTIFICATES, LICENSES, REGISTRATIONS
Must possess an active license in Texas within 30 days of start date.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this Job, the employee is regularly required to sit; use hands to handle or feel; talk; and hear.
• For this position the percentage of expected Travel is: 15%-20% of the time
