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Clinical UM Pharmacist
Healthfirst. Monitor and review prior authorization requests for medications .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in prior authorization reviews, clinical criteria development, and compliance with CMS and NYSDOH regulations. Possesses strong clinical knowledge of pharmaceuticals, effective communication skills, and proficiency in data analysis and reporting.
Highest-signal resume keywords
Pharmacy DegreeRegistered Pharmacist LicensePrior Authorization Review ExperienceClinical Knowledge of PharmaceuticalsKnowledge of CMS Regulations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Criteria DevelopmentDrug Utilization ReviewBilling Practices KnowledgeCritical ThinkingProblem-Solving
Soft Skills
Clinical Writing SkillsVerbal Communication SkillsAbility to Lead Meetings
Tools & Technologies
Microsoft OutlookMicrosoft WordMicrosoft PowerPointMicrosoft ExcelPivot Tables
Certifications & Qualifications
Registered Pharmacist in New York
Industry Keywords
Prior AuthorizationUtilization ManagementCMS ComplianceNYSDOH ComplianceSpecialty Pharmaceuticals
About the role
Key responsibilities & impact- Monitor and review prior authorization requests for medications
- Calculate appropriate billable units based on dosing, indication, weight, BMI, and other clinical considerations
- Develop clinical criteria and medical policies for medication reviews
- Ensure clinical criteria comply with CMS and NYSDOH requirements
- Research drug information and maintain drug and disease-state knowledge
- Perform and present drug utilization reviews for medical benefit medications
- Complete prior authorization reviews within CMS and/or NYSDOH timeframes
- Work across departments to complete Utilization Management reviews
- Review monthly reports and present trends, efficiency and innovation ideas, and medical spend
- Assist in regulatory and compliance audits for all plans
- Ensure activities comply with applicable regulations
- Perform additional duties as assigned or required
Requirements
What you’ll need- Pharmacy degree from an accredited school of pharmacy
- Registered Pharmacist in the state of New York with a license in good standing
- Minimum of 1 year experience conducting prior authorization reviews
- Strong clinical knowledge of pharmaceuticals and disease states
- Strong clinical writing and verbal skills
- Demonstrated critical thinking and problem-solving skills
- Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits
- Interest in growing skills in a dynamic environment
- Knowledge of Centers for Medicare and Medicaid Services regulations, including National and Local Coverage Determinations
- Ability to lead large and small working meetings
- PC skills with Microsoft Outlook, Word, PowerPoint, and Excel, including Pivot tables
Benefits
Comp & perks- Medical, dental and vision coverage
- Incentive and recognition programs
- Life insurance
- 401k contributions
- Competitive compensation and benefits package