Manager Aetna Utilization Review Jobs in Rochester, NY

• Utilization Management (UM) Focus: The clinical pharmacist position is responsible for and participates in a wide range of provider, patient, employer initiatives and programs. The pharmacist supports all of our lines of business which include Medicare, Commercial, Exchange (Marketplace) and Medicaid and manage quality, appropriateness, safety and cost for those member populations.
• Medication Therapy Management (MTM) Focus: The MTM Pharmacist will be responsible for reviewing targeted patients' prescription and medical claims history to identify opportunities to improve therapeutic outcomes & reduce the risk of adverse events. The primary function will be telephonic consultations with our members to provide education & coaching as well as to identify potential opportunities to improve patient care. The position will also require interaction with prescribers to facilitate appropriate changes to medication regimens.

Serves as a representative of FLRx pharmacy management on specific quality/disease management initiatives.

• As a member of the DUR team , conducts evaluations, and prepares reports and recommendations on plan, member, provider and employer prescribing profiles
• Participates in and may take leadership on specific utilization evaluation projects.

• For Internal Staff/departments: Serves as a key contact and clinical pharmacy consultant on medication issues for all internal staff/departments
• Employer group Support/consultation: Supports Employer Clinical Consultation Team and Sales/Marketing in serving as a clinical pharmacy expert for our employer clients
• Community Providers (prescribers, physicians, pharmacy): Provides comprehensive support both directly to the providers and indirectly to the pharmacy help desk/customer service by assisting them with questions and issues arising from the community (physicians/members/pharmacy personnel)
• Provides guidance, instruction and mentoring of pharmacy and other health care students involved in experiential rotations in the department

• Serves as a participant in the DI program by supporting/covering the provider and/or member) information hotline, answering questions, conducting literature searches and formulating drug information responses and documents
• Serves as a resource to internal and external customers relative to specific therapeutic topics where the clinical pharmacist is considered a content expert
• Assists in the development of clinical information documents intended for a wide range of uses, including committee support, database application, newsletters, TIP sheets, etc

• Perform telephonic Comprehensive Medication Reviews with members enrolled in the MTM program
• Participates in the MTM core team meeting to help maintain and improve the program
• Perform physician outreach for the CMS mandated Opioid DUR initiative
• Work with leadership to develop clinical programs that can assist with improving STAR measures, reduce hospital admissions and improve outcomes
• Develop written documents for members and providers regarding drug therapy strategies such as inappropriate use, over/under utilization, gaps in care, etc.

• Pharmacy Degree and NY State Licensure for a newly graduated clinical pharmacist with internship experience in an organized health care setting or in a practice environment with direct physician interaction, clinical practice, data analysis and/or benefit interpretation process experience
• Must possess strong customer service orientation and the ability to interface effectively with internal and external customers
• Fundamental knowledge of drug information process/references and ability to conduct research
• Strong clinical pharmacy experience including participation in patient management initiatives
• Able to serve as a professional, articulate and knowledgeable liaison to internal and external organizations, to foster positive relationships with our vendor/partners, and to appropriately advocate for the corporation
• Strong computer skills. Proficient knowledge of Microsoft Word and Excel
• Excellent verbal and written communication skills with experience communicating with patients (our members) and health care professionals
• Knowledge and skill to conduct a thorough drug regimen review. Strong clinical knowledge base, kept current through continuing education and professional affiliations
• Maintains confidentiality and uses only the minimum amount of protected health information (PHI) necessary to accomplish job related responsibilities
• Strong computer skills. Able to learn new systems
• Basic knowledge of CMS minimum standards for MTM services is desired.

• Normal office environment, with work outside of normal office hours required at times
• Significant time spent at a computer and using the telephone
• Frequent faced paced environment requiring ability to effectively manage multiple projects at the same time, while maintaining attention to details and accuracy- Frequent variation in tasks, at times responds to problems/emergencies or is given special projects
• Very high level of interpersonal interaction. Frequent to constant interaction outside immediate work area and with external customers
• Very high profile position with significant contact with outside vendors, providers and customers at the highest levels
• Ability to travel frequently across New York State and neighboring areas is required. Some travel required out of area. Must have ability to travel
• High problem solving abilities, recognizes problems, develops problem-solving strategies and evaluates the effectiveness of solutions