Remote Utilization Review Jobs in Maine (NOW HIRING)

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of"people caring for people," Martin's Point employees are on amission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary
 The Health Plan Clinical Pharmacist is responsible for development and execution of clinical initiatives/programs around medication management that ensure high quality and cost-effective care for the populations MPHC serves. This position provides clinical pharmacy expertise to Martin's Point Mail Order Pharmacy, practices, and health plan partners and works closely with the contracted Pharmacy Benefits Manager (PBM).
Job Description

PRIMARY DUTIES AND RESPONSIBILITIES

• Assists in the development and implementation of clinical pharmacy strategies which result in high-quality, cost-effective pharmacy management and outcomes.
• Identifies and develops programs/initiatives to achieve evidence-based cost-savings for pharmaceutical utilization.
• Monitors and supports pharmacy-related quality measures (e.g., Medicare Star Ratings, HEDIS) to drive performance improvement and member outcomes.
• Collaborates with internal quality and population health teams to identify medication-related gaps in care and support interventions.
• Serves as a drug information expert and resource regarding the clinical use of drugs for MPHC mail order pharmacy, health plan team members, and MPHC-affiliated practices.
• Supports the development and maintenance of Health Plan Drug Formulary.
• Coordinates and participates in the implementation and review of drug prior authorizations and other pharmacy Utilization Management (UM) activities for various product lines including approval and denial of authorizations based on approved criteria.
• Develops educational materials, newsletters, member and provider talking points and disseminates clinical information for both internal and external audiences.
• Pursues active membership in professional organizations and seeks continual professional development to identify industry trends and best practices and innovative solutions to current and emerging industry challenges.
• Assists other Martin's Point staff on drug information questions, clinical initiatives, benefit design and interpretation, claims processing issues and marketing support.
• Ensures pharmacy and PBM systems reflect accurate benefit and drug coverage.
• Assists in resolving claims adjudication problems when clinical expertise is needed.
• Participates in activities to ensure compliance with Department of Defense and Medicare Part D regulations.
• Develops and revise policies, procedures, and protocols as needed.

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

POSITION QUALIFICATIONS

Education:

• Pharm.D. or BS in Pharmacy with relevant clinical experience

Licensure/certification:

• Current license/eligible for licensure to practice pharmacy in ME.
• License must be unrestricted to perform UM functions as described in Key Outcomes.

Experience:

• 3+ years of retail, hospital, or managed care pharmacy experience

Knowledge:

• Extensive knowledge of drug products, medical therapeutics, pharmacokinetics, and disease states.
• Knowledge of PBM third party billing, pharmacy claims processing, and pharmacy data management

Skills:

• Excellent customer services skills.
• Superior written and verbal communication skills.
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint).
• Strong organizational skills (ability to prioritize and multi-task while maintaining focus on objectives).
• Strong interpersonal skills and the ability to collaborate with internal and external clients

Abilities:

• Strong mathematical ability.
• Thorough clinical knowledge of therapeutic drug utilization.
• Ability to function independently with sound judgment in decision making.
• Take appropriate initiative while soliciting input/advice appropriately.
• Ability to handle confidential and sensitive information in a discreet and professional manner.
• Demonstrated ability to review & analyze data.

Pay Range: $137,952.45 - $170,411.85 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan. In addition to base compensation, we offer a comprehensive benefits package including medical, dental, vision, retirement savings with employer contributions, paid time off (including volunteer time off!), pie day, and other employee benefits.
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org

Do you have a question about careers at Martin's Point Health Care? Contact us at:jobinquiries@martinspoint.org