Clinical Pharmacy Specialist - Aspire Health

Responsibilities

• Utilization Management: Prior Authorization for Medical and Pharmacy Benefit (Medicare Part B and Part D; Commercial Plans)
• Input, review and decision Medicare Part B requests for J codes, Q codes, and other medical benefits drugs/supplies.
• Track and triage coverage determinations and/or prior authorization requests submitted from providers and determine if a pharmacist review is required.
• Monitor prior authorization system to ensure turnaround times are met and contact providers for additional information to facilitate coverage determination reviews.
• Refer coverage determination requests for specialty drugs to a delegated vendor or client for processing when applicable.
• Communicate prior authorization criteria, pharmacy benefit coverage, and formulary alternatives to physicians, physician`s office staff, medical management staff and/or pharmacists.
• Notify physicians, providers, and members of coverage determination request decisions.
• Oversight and preparation of correspondence, proposals, reports, spreadsheets, and forms.
• Assist in maintaining policies & procedures, including editing, proofreading.
• Provide project management assistance to pharmacist and team as needed.
• Support member and provider calls regarding authorization, benefit inquiries, and resolution of pharmacy-related member questions as well as outbound customer service calls to members and delegated partners.
• Coordination and completion of intake/processing for pharmacy and medical authorization and appeal requests. Perform preliminary review for completeness and appropriate documentation. Triage and escalate to the appropriate clinical resource when needed.
• Utilize knowledge of member eligibility and benefit coverage information to respond accurately to authorization requests, which do not require review/consultation by a pharmacist.
• Support the pharmacist or Pharmacy Director with quality and STARS related measures, including outreach to members, providers, and pharmacies.
• Formulary Support
• Assist the Director in maintenance of the formulary and processing formulary change requests on a weekly basis.
• Support team in generating, maintaining, and reviewing Formulary Status Grids.
• Assist pharmacist in audits and quality checks on the current formulary status for accuracy and contract compliance.
• Appeals and Grievances
• Responsible for intake/entry and investigation/resolution of all prescription-related grievances received by the Plan or PBM
• Identify validity of appeal and send request to correct department as appropriate.
• Other appeal tasks as required.
• Audit and Reporting Support
• Assist pharmacist in a range of tasks necessary for pharmacy audit and recovery functions, including: Perform audits and quality checks on active prior authorizations claims.
• Review paid claims for quantity and/or billing discrepancies.
• Investigate member complaints and documentation of findings according to Fraud Waste and Abuse (FWA) program.
• Communicate or fax inquiries to pharmacies related to review findings and updates pharmacy database with incoming phone calls, faxes, and e-mails.
• Responsible for the maintenance of consistent processes and updating of policies and procedures and standard operating procedures as assigned.
• Assist pharmacist with department preparation for internal and external audits (building case files, universes, evidence of compliance and other documentation as needed)
• Medicare Part D Operations, including: Assist with identifying and correcting

Benefits

Additional Information

Welcome to Montage Health's application process! Job Description: The Clinical Pharmacy Specialist will perform duties in the following areas across all lines of business, including Utilization Management, Formulary Support, Appeals and Grievances, and Audit and Reporting Support to support the pharmacy team. This position will perform duties reviewing coverage for medications under the pharmacy and medical benefits for all lines of business necessary. The Clinical Pharmacy Specialist utilizes established company guidelines to review requests from physicians, medical groups, pharmacies, and members for the utilization of prescription drugs and pharmacy benefits. The specialist will conduct, research, and resolve any inquiries, problems, or issues in a timely manner. The Clinical Pharmacy Specialist is responsible for supervising and directing the support services needed for pharmacy services across all lines of business. This team member will continuously look for ways to improve processes and contribute to corporate and department objectives by processing all requests in a prompt, professional and courteous manner.

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