Lead Clinical Care Prior Authorization Pharmacist

Position Summary:

The Lead Clinical Care Prior Authorization Pharmacist will oversee and manage the daily clinical pharmacy functions related to prior authorization reviews, override requests, member/provider education and phone support. The Clinical Care Lead Pharmacist will ensure the efficient processing of medication requests while adhering to medical necessity and contractual criteria. This role will also involve supporting Clinical care pharmacists, providing guidance and ensuring high-quality performance in alignment with company goals, regulatory standards, and client requirements.

Position Responsibilities:

• Perform and oversee day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.

• Support the training and development of staff, helping them enhance their skills and knowledge.

• Contribute to quality improvement initiatives, providing input to projects and programs aimed at improving clinical operations

• Collaborate with business and clinical partners across the organization to improve workflows and ensure consistency in processes.

• Promote a collaborative team environment and provide guidance on best practices for clinical pharmacy services.

• Lead projects aimed at improving pharmacy operations, member care, and clinical outcomes.

• Work on scheduled shift please see schedule details under minimum qualifications section for required working hours

• Serve as a subject matter expert (SME) on clinical medication reviews or issues and provide consultation to the pharmacy team, healthcare provider, and other stakeholders.

• Monitor and queue management to ensure both regulatory and internal compliance requirements are met.

• Collaborate with the compliance, quality assurance and other pharmacy teams to identify risk mitigation strategies, ensuring timely and accurate processing of clincal reviews.

• Make clinical decisions in accordance with medical necessity and contract criteria

• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers

• Communicate effectively with providers and members to promote positive health outcomes

• Provide backup support to call center team as required

• Review pharmacy claims data for proactive outreach and intervention

• Identify and monitor inappropriate trends in care to improve quality and cost effectiveness

• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements

• Work with business and clinical partners as needed

• Ability to work in a fast-paced environment with shifting priorities

• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

• Shift 2:00pm-11:00pmEST with rotating weekends

Minimum Qualifications:

• Active, unrestricted pharmacist license

• Bachelor's or Doctor of Pharmacy Degree with 2+ years of pharmacy practice experience

• Experience in customer service, call center and prior authorization

• Excellent communication, writing, and organizational skills

• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven call center environment

• Self-motivated and detail-oriented problem solver

• Ability to handle multiple competing priorities in a dynamic environment and collaborate in a team

• Have a designated workspace (an office, spare bedroom, etc) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations

• Have the following internet connectivity: DSL, cable modem or fiber with a wired connection to device (wi-fi not allowed). Internet speed of one gigabyte (940bps) is required

• Working knowledge of MS Office