Clinical Pharmacist, Utilization Management

About the role

This position participates in a wide range of provider, patient, and employer initiatives and programs across Medicare, Commercial, Exchange (Marketplace), and Medicaid lines of business. The UM Pharmacist ensures the quality, appropriateness, safety, and cost-effectiveness of medications for members by managing drug utilization across pharmacy and medical benefits.

Essential Accountabilities

• Level I
  • Conduct drug prior authorization, exception, and medical necessity reviews.
  • Work with providers or internal staff to determine whether submitted clinical information and patient presentation meet approval criteria per drug policy, formulary availability, and coverage criteria.
  • Conduct first-line appeal and grievance reviews for medical and pharmacy drugs in accordance with compliance standards.
  • Perform comprehensive reviews and document findings for submission to the medical director for final determination as required by law.
  • Provide direct support to providers and pharmacies to expedite member treatment.
  • Communicate effectively with community providers for clinical callbacks, offering next-step options based on line-of-business analysis and completed review levels.
  • Provide drug information support to medical directors during clinical calls with prescribers.
  • Present quarterly CAU review and analysis to the clinical team and compliance department.
  • Participate in monthly case consistency meetings with cross-functional business areas.
  • Contribute to the maintenance and addition of clinical information on the UM team’s SharePoint site.
  • Demonstrate high standards of integrity aligned with Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct and Lifetime Way values.
  • Maintain high regard for member privacy in accordance with corporate privacy policies and procedures.
  • Ensure regular and reliable attendance.
  • Perform other functions as assigned by management.
• Level II (in addition to Level I)
  • Maintain assigned policies (e.g., infertility, compounding, off-label reviews) and stay current with clinical guidance and company strategy.
  • Provide guidance, instruction, and mentorship to pharmacy and healthcare students on experiential rotations.
  • Take lead role in audits as necessary.
  • Facilitate onboarding and training of new hire pharmacists.
  • Collaborate with the Decision Criteria Coordinator to maintain and update decision criteria and denial language.
  • Research subrogation questions and determine appropriateness of retroactive payment.
• Level III (in addition to Level II)
  • Identify and troubleshoot issues arising during use of care management tools.
  • Guide Level I/II teammates on clinical decision-making and UM process to ensure compliant, consistent, and high-quality work.
  • Revise and organize key documents used by UM staff to support case consistency.
  • Conduct monthly quality assurance reviews for pharmacy reviews and identify issues and cases for coaching and process improvements.
  • Present at meetings to share information and processes with team members.
  • Participate in internal policy discussions with supervisors to ensure consistency.
  • Ensure affiliated team members receive necessary support.
  • Take lead role in audits as necessary.
  • Participate in cross-functional, company-wide workgroups.

Minimum Qualifications

We use a differentiated approach with multiple levels based on demonstrated knowledge, skills, and ability to manage increasingly complex assignments and responsibilities.

• All Levels
  • Unrestricted and current New York State Licensed Pharmacist.
  • Pharm.D. required. In lieu of Pharm.D., a Bachelor’s in Pharmacy is accepted.
  • Managed care experience strongly preferred, especially in utilization management. In lieu of managed care experience, proven success in high-volume retail or hospital pharmacy is accepted.
  • Experience in an organized healthcare setting or practice environment with direct physician interaction, data analysis, and/or benefit interpretation is strongly preferred.
  • Strong customer service orientation and ability to interface effectively with internal and external customers.
  • Fundamental knowledge of drug information processes/references and ability to conduct drug and disease information research.
  • Ability to serve as a knowledgeable liaison to internal and external organizations, fostering positive relationships with vendors/partners and advocating appropriately for the corporation.
  • Strong computer skills, including proficiency in Microsoft Word and Excel.
• Level II (in addition to Level I)
  • Minimum of two years’ experience in a managed care setting, specifically in utilization management.
  • Experience and skillset in a therapeutic or pharmacy management area critical to the Health Plan’s strategic programs.
• Level III (in addition to Level II)
  • Minimum of five years’ experience in a managed care setting, specifically in utilization management.
  • Demonstrated proficiency and expertise sufficient to manage and be accountable for a specific business area (e.g., specialty drugs, Medicare drug, rebate management, audit functions).
  • In-depth understanding of utilization management best practices, Drug List Policies (DLPs), and guidance.

Physical Requirements

• Ability to work prolonged periods sitting and/or standing at a workstation and using a computer.
• Ability to work while sitting or standing at a workstation viewing a computer and using a keyboard, mouse, and/or phone for three or more hours at a time.
• Ability to work in a home office for continuous periods 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.

Pay

E9: $110,093 – $198,168 (actual salary varies based on qualifications, internal equity, and budget factors).