Remote Utilization Review Jobs in Worcester, MA (NOW HIRING)

GENERAL SUMMARY OF POSITION:

Under the general direction of the Manager or Consultant Pharmacist Team Lead or designee, the Consultant Pharmacist IV functions as a team member of the drug utilization review and medication management therapy programs within Clinical Pharmacy Services (CPS). CPS is responsible for administering client-specific programs to provide clinical expertise in regards to prior authorization for member prescriptions and client member’s drug therapy. This position will participate in prospective and retrospective DUR activities including, but not limited to: handling live calls from physicians and pharmacists, reviewing appropriate drug therapy, coordinating and managing the request for prior authorization process, and participating in the development of clinical drug use criteria. This position will also be responsible for the orientation, training and indirect supervision of the Consultant Pharmacists and Pharmacy Associates.

MAJOR RESPONSIBILITIES:

• Provides orientation, training, guidance and direction, to Consultant Pharmacists and Pharmacy Associates
• Coordinates the request for prior authorization (RPA) process including the data entry and the generation of reports that stem from this process, as well as ensure compliance with the federal twenty-four hour time limit.
• Participates in program planning and development.
• Participates in the development of clinical drug use criteria for the prospective and retrospective review components of the DUR Program.
• Researches member’s case and may represent the client during appeal processes regarding prescription medications.
• Performs medication therapy management comprehensive and targeted medication reviews of medical and medication profiles
• Reviews member’s medical and medication profiles and interacts with health care providers and client members to review appropriate drug therapy.
• Provide real-time drug therapy recommendations to prescribers
• Reviews clinical documentation submitted by treating physicians and pharmacists to determine medical necessity and program compliance.
• Decides in real time via telephone communications with pharmacies the authorization or denial of prior approval requests for prescription medications.
• Provides pharmaceutical expertise and knowledge to the advisory board’s clinical workgroups.
• Monitors over-utilization and under-utilization of prescribed medicines for members.
• Assists in monitoring and researching profiles for compliance on a daily basis.
• Refers suspected abuse and fraudulent members to the program manager or designee for case review.
• Participates in site visits to Provider offices, as necessary.
• Participates in agency meetings as requested.
• Leads and participates in quality improvement and quality assurance initiatives
• May perform other job related duties as assigned or requested.

REQUIRED QUALIFICATIONS:

• Bachelor of Science degree in Pharmacy with 3 years of work experience OR

• Doctor of Pharmacy degree with 2 years of pharmacy-related work experience or completion of 2 years of pharmacy residency OR
• Doctor of Pharmacy degree with completion of 1 year of pharmacy residency and 1 year of pharmacy-related work experience OR
• Doctor of Pharmacy degree with completion of managed care residency program

• Eligibility for licensure or current pharmacist license in good standing in the Commonwealth of Massachusetts
• Ability to travel to off-site locations

PREFERRED QUALIFICATIONS:

• Previous medical and medication review experience
• Bilingual fluency in reading, writing and speaking English and one other major language