Pharmacist I, Clinical Prior Authorization

About Us

Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.

ATTENTION: Navitus is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

Overview

Navitus Health Solutions is seeking a Pharmacist I, Clinical Prior Authorization to join our team!

The Pharmacist I, Clinical Prior Authorization will be responsible for: performing Prior Authorizations; perform duties related to Drug Utilization Review including concurrent, retrospective, and prospective components; and support Customer Care with clinical calls requiring pharmacist intervention. The Pharmacist I, Clinical Prior Authorization is also responsible for interfacing with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries’ benefits and therapeutic interventions, and reviewing/evaluating the health surveys and utilization data for program management and development.

Is this you? Find out more below!

Responsibilities

How do I make an impact on my team?

• Responsible for support and input to clinical programs such as: Health Management, Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high quality, cost effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place
• Participate in the Coverage Determination (Certification, Prior Authorization, Medical Exception, Exception to Coverage, etc.) process by reviewing all requests which are not clearly approvable based on specified criteria (algorithms), making all coverage denial determinations, and identifying themselves by first name, title, and responsibility at Navitus in relation to drug utilization management program administration
• Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers
• Provide input to clinical content of new programs and for maintenance of existing programs
• Complete all annual URAC training requirements
• Facilitation of communication and education to clients, members, and internal staff regarding clinical daily issues and objectives
• Provide support to operational departments on the implementation of various PBM programs and daily functioning in support of member/patient quality of care
• Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee
• May review healthcare survey data for Medicare Part D qualified participants and/or perform phone consultations with Med-D enrollees; aid in documentation of calls; designate enrollees for repeat interaction
• Other duties as assigned

Qualifications

What our team expects from you?

• A minimum of a bachelor’s degree in Pharmacy or Pharm D. Current unrestricted licensure as an RPh in the State of the home office of the pharmacist or the ability to gain reciprocity within 4 months of employment is required
• Two years’ work experience in a clinical setting, or clinical or managed care pharmacy practice residency preferred
• Knowledge of PBM industry, formulary management, pharmacy claims and managed care principles and practices desired
• Exceptional clinical skills and ability to apply sound clinical judgment to a variety of situations is necessary
• Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline, Internet) preferred
• Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences
• Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
• Requires attention to detail to assure projects are clinically, editorially, and systems accurate and can be operationalized
• Proficiency in MS Word, Excel, Power Point including tables, charts and figures preferred
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• 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!

Key skills/competency

• Prior Authorization
• Drug Utilization Review
• Clinical Programs
• Pharmacy Benefit Management
• Managed Care
• Formulary Management
• Clinical Judgment
• Problem-Solving
• Attention to Detail
• Communication