Clinical Pharmacist Consultant Prior Authorization
Cambria Health, Inc.
Clinical Pharmacist Consultant - Prior Authorization
Remote in ID, OR, WA, UT
Primary Job Purpose
Provides clinical pharmacy expertise evidence-based medicine to determine medication coverage, with a focus on prior authorization. This may include providing coverage recommendations for medications subject to prior authorization, appeals, retrospective claim reviews, and audits based on applicable medication coverage policies, member benefit contracts, and provider contracts. In addition, the pharmacist will serve as a resource regarding clinical, policy, benefit questions, and interventions for other staff, such as medical directors or case managers. May also provide direct outreach to members and providers.
This role may also assist in developing, and implementing clinical strategies with respect to formulary management, drug utilization management, peer to peer conversations, drug education, and/or case management strategies. Advanced responsibilities may include analyzing health care cost information, medication coverage policies, formulary monographs and, cross-functional projects.
General Functions and Outcomes
The main responsibility of this role will be conducting prior authorization reviews and peer-to-peer conversations with external providers.
Provide coverage recommendations for medications subject to prior authorization, appeals, retrospective claim reviews, and audits based on applicable medication coverage policies, member benefit contracts, and provider contracts.
Provides sound clinical decision-making based on best practice in applying evidence-based medicine process in determining medications that have best value for efficacy and safety.
Develops and provides informational materials and correspondences to providers and members to communicate medication coverage choices, comparative effectiveness, and coverage determinations.
Provides creative thinking and leadership in accomplishing goals of quality improvement and cost-effective prescription drug programs.
Collects, analyzes, interprets and forecasts health care cost information based on current prescribing patterns based on medication utilization reports.
May develop medication coverage policies formulary monographs, and formulary coverage recommendations based on critical appraisal of the scientific literature and input from practicing providers.
Presents and/or communicates clinical positions on medication analysis in a clear, concise manner.
May present formulary and medication coverage considerations to internal and external decision-making bodies such as the Pharmacy and Therapeutics Committee and Medication Policy Group.
May identify, develop, implement, and track complex cross-functional programs, projects, and initiatives related to the provision of pharmacy benefits that impact safety, quality, and affordability.
May support the execution, development, and maintenance of clinical programs.
May empower Case Management to provide comprehensive member support.
Strong clinical pharmacy background with ability to demonstrate clinical skills and knowledge in a clinical care setting.
Ability to utilize clinical background to read, interpret, and utilize clinical policies to make coverage decisions.
Demonstrated success in managing professional relationships in a managed care system, medical group, hospital, pharmacy or related organizations.
Excellent verbal and written communication skills; strong business analytical abilities, and strong project management and coordination abilities.
Strong knowledge of medications, state and federal laws and regulations regarding the practice of pharmacy, and regulation of health care industry practices.
Strong knowledge of health care economics; health care/pharmaceutical industry dynamics, and pharmacy/provider service medication reimbursement of medications.
Knowledge of health plan and benefit design structures and application, Medicare/CMS regulations and applicability in administering the Medicare Product, and health care coding and payment systems (such as ICD-9, CPT, HCPCS, NDC).
Strong knowledge of compliance related activities, legislative and regulatory activities, health insurance operations, and legal issues.
Ability to collaborate as part of cross functional teams, improve clinical programs, enhance processes, and share clinical information.
Ability to work independently, prioritize work, meet deadlines, and achieve operational goals.
Normally to be proficient in the competencies listed above:
Clinical Pharmacist Consultant would have a Bachelor’s degree in Pharmacy or Doctor of Pharmacy (PharmD) or related field and 3-5 years of experience in clinical acute care/hospital setting or equivalent combination of education and experience.
Required Licenses, Certifications, Registration, Etc.
Pharmacy license. Successful completion of a pharmacy residency or advanced degree in health-related field preferred. Must be an active and unrestricted licensed pharmacist in state of practice.
The expected hiring range for a Clinical Pharmacist Consultant is $117,500 - $159,500 depending on skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The bonus target for this position is 15% . The current full salary range for this role is $110,500 - $180,500.
Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:
medical, dental, and vision coverage for employees and their eligible family members
annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
paid time off varying by role and tenure in addition to 10 company holidays
up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
one-time furniture and equipment allowance for employees working from home
up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.