Responsible for developing, defining, maintaining and instituting a prior authorization quality assurance program for the Pharmacy Technician and Pharmacist clinical review function
Responsible for summarizing quality assurance activities and presenting to leadership and the Clinical Review Team
Responsible for developing, maintaining and conducting an interrater reliability program
Monitors clinical appeals to further enhance the prior authorization program
Collaborate with Pharmacists within the Pharmacy and Therapeutics Committee and Criteria Review Committee process and participate in development of clinical criteria for medications requiring prior authorization
Identifies opportunities for technology enhancements, process improvement or coaching for team members
Collaborate with Clinical Review Business Analyst to support system enhancements
Support Policy and Procedure development and maintenance
Become a subject matter expert on department standards and processes

Bachelor’s degree in Pharmacy or Doctor of Pharmacy (PharmD) required
Active Pharmacist License required
5+ years of health plan or pharmacy benefit manager experience, specifically involved in prior authorization review required
2+ years of experience conducting prior authorization quality audits required
2+ years of experience designing and developing quality assurance best practices in a startup environment highly desired.
Proficiency in Mac, MS Office, G-Suite required
Active listening, conversational speaking skills, with a high degree of empathy
Self-starter with ability to multitask, prioritize and manage time effectively
Ability to communicate clearly, present complex information to members, clients, pharmacies, providers, and other teams internally
Flexibility and ability to adapt to changes and updates to processes and protocols
Demonstrate accurate drug product/dose calculations for appropriate claim adjudication and knowledge of general pharmacy and drug product information for the prescription filling process

Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life Insurance and AD&D Insurance
Flexible Spending Benefits
401(k) Retirement Savings Program
Short-term and long-term disability
Discretionary Paid Time Off
12 Paid Holidays
Wellness Benefits
Commuter Benefits
Paid Parental Leave benefits
Employee Assistance Program (EAP)
Well-stocked kitchen in office locations
Professional development and training opportunities

Clinical Review Quality Assurance Pharmacist

Key skills