[Hiring] Clinical Grievance and Appeals Pharmacist @Navitus Health Solutions, LLC

Role Description

Due to growth, we are adding a Clinical Grievance and Appeals Pharmacist to our team. The Clinical Grievance and Appeals Pharmacist will be responsible for:

• Performing Appeals and Redeterminations
• Conducting Grievance Quality of Care reviews
• Performing duties related to Drug Utilization Review including concurrent, retrospective, and prospective components
• Serving as a liaison and clinical support for the Grievance and Appeals staff for clinical calls requiring pharmacist intervention
• Interfacing with physicians, pharmacists, and specialty pharmacy providers regarding beneficiaries’ benefits and therapeutic interventions
• Reviewing/evaluating health surveys and utilizing data for program management and development
• Coordinating with Clinical Account Executives and Program Managers to enhance support and understanding of related Pharmacy Benefit Management (PBM) programs
• Developing and maintaining appropriate clinical, evidence-based documentation that supports PBM programs
• Ensuring that Navitus can provide clinically sound programs and medications in a cost-effective manner
• Utilizing technology to implement online PBM programs

Qualifications

• A minimum of a bachelor’s degree in Pharmacy or Pharm D
• Current unrestricted licensure as an RPh in the State of the home office of the pharmacist, or the ability to gain reciprocity within 4 months of employment
• Preferred experience: a minimum of two years of clinical experience, or clinical or managed care pharmacy practice residency
• Knowledge of PBM industry, formulary management, utilization review, pharmacy claims, and managed care principles and practices
• Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline)
• Ability to reason and translate clinical information for clinical systems and clinical/non-clinical audiences
• Emphasis on problem-solving skills, including identifying and accepting challenging situations and creating and implementing solutions
• Strong attention to detail to assure projects are clinically, editorially, and systems accurate
• Proficiency in MS Word, Excel, and PowerPoint including tables, charts, and figures
• Participation in, adherence to, and support of compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

Requirements

• Responsible for support and input to clinical programs such as Health Management, Drug Utilization Review, Formulary development, and clinical programs
• Perform quality reviews of Prior Authorization forms, denial language, and PA Accel
• Continually monitor the quality and efficiency of the Appeals, Redetermination, and Grievance process
• Review Grievances, Appeals, Complaints, and Redeterminations following all CMS, state, client, and Navitus standards
• Provide input to clinical content of new programs and for maintenance of existing programs
• Participate in audits, on-site or remote audits, as a clinical subject matter expert
• Support/provide clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee
• Learn and understand the up and downstream processes related to grievances and appeals
• Contribute to the management of grievance and appeal resources/materials
• Other duties as assigned

Benefits

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!