Pharmacist - Managed Care Auth Reviewer REMOTE
Pharmacist - Managed Care Auth Reviewer REMOTE
Posted on :
11-04-2025
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1 Vacancy
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Job Description
We are currently hiring aParttime Managed Care Pharmacist Authorization Reviewer! If you have managed care pharmacy benefit experience advanced knowledge of medication therapy clinical appropriateness hold an unrestricted Oregon Pharmacist licensure and value being part of a team that makes a difference you may be the right person for the position! Apply today!
JOB SPECIFICATIONS
Classification: NONEXEMPT Status:PARTTIME 25HOURS/WEEK Business Operations are Monday Friday generally 8am to 5pm Pacific Time
Salary: $60 $75/HOURLY
Department: Pharmacy Work Location: REMOTE (OR CA AZ CO TX GA AL MO SD FL)
Reports to: Director of Pharmacy
Supervision Exercised: Nonsupervisory
JOB PURPOSE: Managed Care Pharmacist Authorization Review
This position is responsible for reviewing pharmacy claims and processing pharmacy prior authorizations. By demonstrating consistent application of knowledge and skills they will support the delivery of appropriate safe efficient and costeffective pharmacy services as part of a multidisciplinary team and play a key role in supporting and incorporating principles of populationbased medicine.
QUALIFICATIONS EDUCATION and EXPERIENCE
- Unrestricted clinical licensure as a pharmacist in the state of Oregon
- Bachelors Degree in Pharmacy required; Doctor of Pharmacy preferred
- Managed Care residency or experience preferred
- Three to five years of clinical practice or experience working in a healthcare organization preferred
ESSENTIAL RESPONSIBILITIES: Managed Care Pharmacist and Pharmacy Benefit Coordination
- Maintain working knowledge related to members enrolled in the Oregon Health Plan (OHP)
- Work with Utilization Management Team including Chief Medical Officer MD Reviewer Manager of Medical Services and other staff as appropriate to ensure that authorizations are processed according to organizational and State required guidelines
- Render clinical decisions based on Oregon Administrative Rules Line Finder (prioritized list) prior authorization criteria and Advanced Healths current formulary
- Act as a liaison with pharmacy providers medical providers and thirdparty administrators (Pharmacy Benefit Administrator PBM) to ensure efficient processing of data and claims
- Manage the processing of all pharmacy claims through a PBM in a timely manner
- Analyze claims for appropriateness of services and interprets benefits in accordance with established contracts
- Follow all processes and procedures for consistent output of pharmacy authorization determinations
- Assist in identifying providers with practice patterns which are not in conformity to best practice standards
- Participate in quality and organizational process improvement activities and teams when requested
- Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
- Handle confidential information and materials appropriately and maintains a secure work area
- Other duties as assigned
ESSENTIAL RESPONSIBILITIES: ORGANIZATIONAL TEAM MEMBER
- Participate in quality and organizational process improvement activities and teams when requested
- Support and contribute to effective safety quality and risk management efforts by adhering to established; policies and procedures maintaining a safe environment promoting accident prevention and identifying and reporting potential liabilities
- Openly clearly and respectfully share and receive information opinions concerns and feedback in a supportive manner
- Work collaboratively by mentoring new and existing coworkers building bridges and creating rapport with team members across the organization
- Provide excellent customer service to all internal and external customers which includes team members members students visitors and vendors by consistently exceeding the customers expectations
- Recognize new developments and remain current in positions expertise best practice standards and anticipate organizational modifications
- Advance personal knowledge base by pursuing continuing education to enhance professional competence
- Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
- Represent organization at meetings and conferences as applicable
KNOWLEDGE SKILLS and ABILITIES
- Advanced knowledge of major medication therapy drugdrug interactions and disease states
- Advanced ability to evaluate clinical appropriateness of medication therapy
- Knowledge of managed care concepts principles and operations
- Knowledge of federal and state laws including OSHA HIPAA Waste Fraud and Abuse
- Excellent skills in problem anticipation problem solving and analytical thinking
- Critical thinking skills in using logic and reasoning to identify strengths and weaknesses of alternative solutions conclusions or approaches to problems
- Sensitivity to and supportive of the various missions and purposes of community partners such as education clinical care and community service and benefit
- Interpersonal strengths in influencing effective group processes able to work with internal and external stakeholders of various position levels and responsibilities including physicians and other health care professionals
- Ability to manage plan and adjust work schedule to meet work responsibilities and objectives report to work as scheduled and work a flexible schedule when needed
- Ability to effectively present information and respond to questions from coworkers supervisor and customers
- Ability to work with mathematical concepts such as probability and statistical inference
- Ability to apply concepts such as fractions percentages ratios and proportions to practical situations
- Must be adept at using various applications including database spreadsheet word processing and transactional system software
- Ability to interpret and extensive variety of technical instruction in mathematical or diagram form and deal with several abstract and concrete variables
- Understanding complex medical and behavioral health diagnostic information to assist providers and other care coordinators in treatment planning
- Proficient in Microsoft Office Suite and Windows Operating System (OS)
- Training in or awareness of Health Literacy Poverty Informed Systemic Oppression language access and the use of healthcare interpreters uses of data to drive health equity Cultural Awareness TraumaInformed Care Adverse Childhood Experiences (ACEs) Culturally and Linguistically Appropriate Service (CLAS) Standards and universal access
- Knowledge and understanding of how the positions responsibilities contribute to the department and company goals and mission
- Awareness and understanding of equity diversity inclusion and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social political and environmental contexts of policies programs and practices
- Excellent people skills and friendly demeanor
- Attention to detail and organization skills
- Ability to handle stress and sensitive situations effectively while projecting a professional attitude
- Ability to communicate professionally both conversing and written
- Ability to work with diverse populations and interact with people of differing personalities and backgrounds
- Sensitive to economic considerations human needs and aware of how ones actions may affect others
- Ability to organize and work in a sensitive manner with people from other cultures
- Poised; maintains composure and sense of purpose
WORKING CONDITIONS
This position must have the ability to remain in a stationary position occasionally move about inside the office to access office machinery printer etc. frequently communicate and exchange accurate information.
Work Condition:
- Employee generally works within a remote work from home environment.
- Travel may be required on occasion.
- Hours of operations and specific staff scheduling may vary based on operational need.
Exposed to:Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
Machines equipment tools and supplies used: Constantly operates a computer or other office productivity machinery or software such as fax copier calculator multiline telephone system or scanner.
- May answer a high volume of telephone calls complete documentation and use computer programs to either obtain or record information.
Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task.
This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities duties or responsibilities that are required of DOCS Management Services employees. Other duties responsibilities and activities may change or be assigned at any time with or without notice.
Employment Type
Full Time
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