[Hiring] Pharmacist, Clinical Utilization Management @Navitus Health Solutions, LLC

Role Description

Archimedes is seeking a Pharmacist, Clinical Utilization Management to join our team! The Pharmacist, Clinical Utilization Management is the clinical expert for all specialty medications across both the pharmacy and the medical benefit. This role will communicate with physicians, nurses, pharmacists, and members related to high-cost case concerns, dose management, genetic testing, therapeutic substitutions, and cost management related to specialty drugs.

The Pharmacist, Clinical Utilization Management will serve as a clinical subject matter expert and conduct peer to peer consultations with physicians. This position is divided into two areas:

• External clinical outreach activities related to high-cost case management and prior authorization of specialty medications, across pharmacy and medical benefits and specialty and traditional drugs.
• Evaluate the data to identify actionable opportunities for specialty management and create clinical policies.

Responsibilities include:

• Develop and deliver clinical messages to physicians, members, clients, and consultants.
• Manage prior authorization, high-cost cases, claims editing and clinical policy development.
• Conduct prior authorization outreach to prescribers to obtain clinical information, clarify requests, and support timely case resolution.
• Communicate with prescribers and other clinical stakeholders by phone, email, or fax regarding prior authorization requests, clinical documentation, and benefit requirements.
• Engage in evidence-based clinical conversations with prescribers to explain utilization management criteria, coverage determinations, and appropriate therapeutic alternatives.
• Serve as a clinical resource for member-facing teammates, providing prior authorization guidance, clinical context, and support for member inquiries.
• Communicate directly with members on an as-needed basis to address prior authorization questions and support understanding of clinical or coverage-related information.
• Clinical program development including both medical and pharmacy benefit management.
• Define, document, and deliver results for plan sponsors.
• Evaluate and summarize clinical literature as well as financial implications related to medication management options.
• Present deep clinical and cost effectiveness information as subject matter expert.
• Other duties as assigned.

Qualifications

• Bachelor’s degree in Pharmacy or PharmD degree required.
• Current, unrestricted licensure as a Registered Pharmacist in the state of residence, or the ability to gain reciprocity within 4 months, may be required based on state of residence laws or client contracts. Other State Pharmacy Licenses may be required as business need dictates.
• Board of Pharmacy Certification preferred for Pharmacotherapy, Ambulatory Care or Oncology Care.
• Pharmacy experience in retail, hospital, managed care, or other pharmacy-related setting required.
• Experience and knowledge in Pharmacy and Medical specialty benefits required.
• Proficiency in Microsoft Excel, PowerPoint, and Word required.
• Experience with physician-facing clinical communication preferred.
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees.

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!