Clinical Pharmacist, Utilization Management

We need to output HTML fragment with headings

for sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We need to parse the job posting. The posting includes: - Summary Job Description: description of responsibilities (Essential Accountabilities Level I, II, III). So we can have a "Responsibilities" section with bullet points. - Minimum Qualifications: includes qualifications, experience, education, etc. Could be "Qualifications" and "Skills". We need to separate. - Physical Requirements: maybe part of Requirements? Could be "Requirements" section. - Compensation Range(s): Pay. - Benefits: mention of total rewards package: group health/dental insurance, retirement plan, wellness program, paid time away, paid holidays, remote work possibility. - Schedule: not mentioned explicitly. There's no schedule info. So we should not include Schedule section. - About the role: maybe we can include a brief summary from the Summary Job Description? The instruction says do NOT repeat the job title as a heading. But we can have an About the role section with a paragraph summarizing the role. The posting includes "Summary Job Description: This position is responsible for and participates in a wide range of provider, patient, and employer initiatives and programs..." That could be used for About the role. Thus sections: About the role (p), Responsibilities (ul), Requirements (maybe physical requirements + maybe other mandatory like licensure?), Qualifications (education, experience), Skills (computer skills, customer service, etc.), Benefits (ul), Pay (p with salary range). Possibly also "Qualifications" and "Skills" separate. We must not invent or summarize away detail. Must preserve ALL substantive information. So we need to include all bullet points from Essential Accountabilities (Level I, II, III) as list items. Also include Minimum Qualifications details (education, licensure, experience preferences). Also include Physical Requirements. Also include Compensation Range. Also include Benefits details (group health/dental insurance, retirement plan, wellness program, paid time away, paid holidays, remote work possibility). Also include Equal Opportunity Employer line? That is boilerplate EEO; instruction says remove EEO/equal-opportunity/scam-warning boilerplate. So we should drop that line. Also remove cookie/navigation/legal etc. Not present. We must not include headings with filler text. Ensure each heading has substantive content. Let's craft HTML:

About the role

This position is responsible for and participates in a wide range of provider, patient, and employer initiatives and programs. The pharmacist supports all lines of business including Medicare, Commercial, Exchange (Marketplace) and Medicaid. The focus is to manage the quality, appropriateness, safety and cost of medications for members through medical management of drugs across pharmacy and medical benefits.

Responsibilities

• Conducts drug prior authorization, exception and medical necessity reviews.
• Works with requesting providers or internal staff to determine whether submitted clinical information and patient presentation meet criteria for approval according to drug policy, formulary availability, and specific coverage criteria.
• Conducts first line appeal and grievance reviews for medical and pharmacy drugs in accordance with compliance standards.
• Conducts comprehensive reviews and documentation of findings for submission to the medical director for final determination, as required by law.
• Provides comprehensive support directly to providers and pharmacies, as needed, to expedite treatment of members.
• Communicates effectively with community providers for case discussions on clinical call backs, providing next step options based on line of business analysis and level of reviews already completed.
• Provides drug information support to medical directors during clinical calls with prescribers.
• Presents quarterly CAU review and analysis to the clinical team and compliance department.
• Participates in monthly case consistency meetings in collaboration with different business areas.
• Contributes to the maintenance and addition of relevant clinical information for the UM team’s SharePoint site.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Maintains assigned policies (such as infertility, compounding, and off label reviews) keeping up with current clinical guidance and company strategy.
• Provides guidance, instruction and mentoring of pharmacy and other health care students involved in experiential rotations in the department.
• Takes lead role in audits, as necessary.
• Facilitates the onboarding and training of new hire pharmacists.
• Collaborates with Decision Criteria Coordinator to maintain and update decision criteria and denial language.
• Research subrogation questions and determine whether retroactive payment would be appropriate.
• Identify and troubleshoot issues arising during use of care management tools.
• Guides level I/II teammates on clinical decision‑making and UM process insight to resolve day‑to‑day issues and ensure the team’s work is compliant, consistent, and of high quality.
• Revises and organizes key documents used by the UM staff to support case consistency.
• Conducts monthly quality assurance review for pharmacy reviews and identifies issues and cases for coaching and process changes.
• Presents on meetings to share information and processes with fellow team members.
• Participates in internal policy discussions with supervisors to ensure consistency.
• Ensures that affiliated team members receive necessary support.
• Takes lead role in audits, as necessary.
• Participates in cross‑functional company‑wide workgroups.

Now Requirements: maybe physical requirements plus maybe licensure? But licensure is in qualifications. We'll put physical requirements under Requirements.

Requirements

• Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.
• Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
• Ability to work in a home office for continuous periods of time for business continuity.
• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
• Ability to hear, understand, and speak clearly while using a phone, with or without a headset.

Qualifications: education, licensure, experience preferences.

Qualifications

• Unrestricted and current NYS Licensed Pharmacist.
• Pharm.D.; in lieu of a Pharm.D., a Bachelor’s in Pharmacy is required.
• Managed care experience is strongly preferred, especially experience in utilization management.
• In lieu of managed care experience, proven record of successful experience in a high‑volume retail or hospital pharmacy is accepted.
• Experience in an organized health care setting or in a practice environment with direct physician interaction, data analysis and/or benefit interpretation process experience is strongly preferred.
• Minimum of two years’ experience in a managed care setting, specifically in utilization management (for Level II).
• Minimum of five years’ experience in a managed care setting, specifically in utilization management (for Level III).
• Attained sufficient proficiency, skills and expertise to manage and be accountable for a specific area of business, such as specialty drugs, Medicare drug, rebate management, audit functions, etc. (Level III).

Skills: customer service, drug information, computer skills, etc.

Skills

• Strong customer service orientation and ability to interface effectively with internal and external customers.
• Fundamental knowledge of drug information process/references and ability to conduct drug and disease information research.
• Able to serve as a knowledgeable liaison to internal and external organizations, to foster positive relationships with vendor/partners, and to appropriately advocate for the corporation.
• Strong computer skills; proficient knowledge of Microsoft Word and Excel.
• Skillset in a therapeutic or pharmacy management area critical to the Health Plan’s strategic program (Level II).
• Demonstrates exceptional understanding of process and procedure utilizing the care management tools (Level III).
• Consistently demonstrates an in‑depth understanding of utilization management best practices, DLPs and guidance (Level III).

Benefits: total rewards package.

Benefits

• Participation in group health and/or dental insurance.
• Retirement plan.
• Wellness program.
• Paid time away from work.
• Paid holidays.
• Opportunity for remote work (case‑by‑case basis).

Pay: compensation range.

Pay

Compensation range: E9: $110,093 – $198,168. Actual salary will vary depending on factors including budget, prior experience, knowledge, skill, education, and internal equity.

We should not include Schedule section. Check that we didn't include any boilerplate like EEO. We removed that. Check that we didn't duplicate lines. We have some duplication: "Takes lead role in audits, as necessary." appears twice (Level II and Level III). It's okay to keep both as they appear in original; but we might want to keep only once? The instruction: Preserve ALL substantive information; do NOT invent or summarize away detail. Duplicated lines are part of the original; we could keep both but maybe it's redundant. However they said remove duplicated lines. Actually they said: "Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions." So we should remove duplicated lines. So we need to deduplicate identical lines. Identify duplicates: - "Takes lead role in audits, as necessary." appears in Level II and Level III. Keep one. - "Facilitates the onboarding and training of new hire pharmacists." appears only once. - "Provides guidance, instruction and mentoring of pharmacy and other health care students involved in experiential rotations in the department." appears only once. - "Conducts drug prior authorization, exception and medical necessity reviews." only once. - "Works with requesting providers or internal staff to determine whether the submitted clinical information and patient presentation meet the criteria for approval according to the drug policy, formulary availability, and specific coverage criteria." only once. - "Conducts first line appeal and grievance reviews for medical and pharmacy drugs in accordance with compliance standards." only once. - "Conducts comprehensive reviews and documentation of findings for submission to the medical director for final determination, as required by law." only once. - "Provides comprehensive support directly to providers and pharmacies, as needed, to expedite the treatment of our members." only once. - "Communicates effectively with our community providers for case discussions on clinical call backs, providing next step options based upon line of business analysis and level of reviews already completed." only once. - "Provides drug information support to our medical directors during clinical calls with prescribers." only once. - "Presents quarterly CAU review and analysis to the clinical team and compliance department." only once. - "Participates in monthly case consistency meetings in collaboration with different business areas." only once. - "Contributes to the maintenance and addition of relevant clinical information for the UM team’s SharePoint site." only once. - "Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values