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Clinical Utilization Management Pharmacist
Navitus Health Solutions. Serve as the clinical expert for specialty medications across pharmacy and medical benefits.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in specialty medication management, including prior authorization processes and clinical policy development, while effectively communicating with healthcare professionals and members. Proficient in evaluating clinical literature and delivering evidence-based recommendations for medication management.
Highest-signal resume keywords
Registered Pharmacist LicensurePharmacy Experience in Managed CarePrior Authorization ManagementClinical Communication with PhysiciansMicrosoft Excel Proficiency
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 Policy DevelopmentPrior Authorization ManagementMedication ManagementClinical Literature EvaluationCost-Effectiveness Analysis
Soft Skills
Effective CommunicationCooperative InteractionRespectful Engagement
Tools & Technologies
Microsoft ExcelMicrosoft PowerPointMicrosoft Word
Certifications & Qualifications
Pharmacy DegreeBoard of Pharmacy Certification
Industry Keywords
Specialty MedicationsPharmacy BenefitsMedical BenefitsUtilization ManagementTherapeutic Alternatives
About the role
Key responsibilities & impact- Serve as the clinical expert for specialty medications across pharmacy and medical benefits.
- Communicate with physicians, nurses, pharmacists, members, clients, and consultants regarding high-cost cases, dose management, genetic testing, therapeutic substitutions, and specialty-drug cost management.
- Manage prior authorization, high-cost cases, claims editing, and clinical policy development.
- Conduct prior authorization outreach to prescribers to obtain clinical information, clarify requests, and support timely case resolution.
- Communicate with prescribers and clinical stakeholders by phone, email, or fax regarding prior authorization requests, clinical documentation, and benefit requirements.
- Explain utilization management criteria, coverage determinations, and appropriate therapeutic alternatives through evidence-based clinical conversations.
- Provide prior authorization guidance, clinical context, and support for member-facing teammates.
- Communicate directly with members as needed about prior authorization questions and clinical or coverage-related information.
- Develop clinical programs for medical and pharmacy benefit management.
- Define, document, and deliver results for plan sponsors.
- Evaluate and summarize clinical literature and financial implications of medication management options.
- Present clinical and cost-effectiveness information as a subject matter expert.
- Perform other duties as assigned.
Requirements
What you’ll need- Bachelor’s degree in Pharmacy or PharmD degree required.
- Current, unrestricted licensure as a Registered Pharmacist in the state of residence, or the ability to gain reciprocity within 4 months, may be required based on state of residence laws or client contracts.
- Other State Pharmacy Licenses may be required as business need dictates.
- Board of Pharmacy Certification preferred for Pharmacotherapy, Ambulatory Care or Oncology Care.
- Pharmacy experience in retail, hospital, managed care, or other pharmacy-related setting required.
- Experience and knowledge in Pharmacy and Medical specialty benefits required.
- Proficiency in Microsoft Excel, PowerPoint, and Word required.
- Experience with physician-facing clinical communication preferred.
- Participate in, adhere to, and support compliance program objectives.
- Ability to consistently interact cooperatively and respectfully with other employees.
- Work schedule: M-F 8am to 5pm.
Benefits
Comp & perks- 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!