Manager, Clinical Pharmacist UM

About the role

This is a hybrid position based at 100 Church Street, responsible for the review of prior authorization requests for medications under the medical benefit and hands-on leadership of the Utilization Management (UM) Pharmacy team.

Responsibilities

• Develop clinical criteria and medical policies for provider-administered medications.
• Review monthly reports for quality assurance and stay current with literature, evidence-based medicine, and trends in medicine.
• Collaborate with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions.
• Supervise, evaluate, and coordinate daily team operations to meet departmental productivity goals regarding quality, timeliness, accuracy, and consistency.
• Allocate, monitor, and control resources while delegating and monitoring workloads.
• Assist the Director of Specialty Pharmacy Programs with reviewing team performance and implementing continuous process improvement and quality initiatives.
• Exercise judgment within defined procedures and policies to determine appropriate actions and administer departmental policies.
• Develop and monitor team goals; provide ongoing feedback and coaching; conduct annual performance reviews; foster open communication, teamwork, and empowerment.
• Assist in directing, training, and developing team members by embodying the Trailblazer mindset.
• Build and develop relevant business relationships, critically assess departmental problems, and make informed recommendations.
• Attend, schedule, and present in internal and external departmental meetings.
• Participate in preparation and conducting of regulatory site surveys (NYS Department of Health, Centers for Medicare and Medicaid Services (CMS), Department of Insurance).
• Perform prior authorization reviews as set forth by CMS and/or NYSDOH, ensuring compliance with required timeframes.
• Monitor and review prior authorization requests for medications, calculating appropriate billable units based on dosing, indication, weight, BMI, and other clinical considerations.
• Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews.
• Review monthly reports and provide feedback on trends, ideas for efficiency, and innovation.
• Work weekends, holidays, and as needed to support departmental needs.

Requirements

• Develop clinical criteria and medical policies for the review of medications, ensuring compliance with CMS and NYSDOH guidelines.

Pay

Hiring range for Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430

Hiring range for all other approved locations: $88,700 - $131,920

Salary and related compensation elements will be contingent upon work experience, education, licenses, certifications, and other factors deemed pertinent to the hiring decision.

Benefits

• Medical, dental, and vision coverage.
• Incentive and recognition programs.
• Life insurance.
• 401k contributions.

All benefits are subject to eligibility requirements.