Pharmacist, Clinical Grievance and Appeals

Navitus Health Solutions is seeking a Clinical Grievance and Appeals Pharmacist to join our team!

The Clinical Grievance and Appeals Pharmacist will be responsible for performing Appeals and Redeterminations, Grievance Quality of Care reviews, perform duties related to Drug Utilization Review including concurrent, retrospective, and prospective components, and serve as a liaison and clinical support the Grievance and Appeals staff for clinical calls requiring pharmacist intervention. The Clinical Grievance and Appeals Pharmacist is also responsible for interfacing with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries' benefits and therapeutic interventions. Additional responsibilities include reviewing/evaluating the health surveys and utilizing data for program management and development. The Clinical Grievance and Appeals Pharmacist will coordinate with Clinical Account Executives and Program Managers to enhance their support and understanding of related Pharmacy Benefit Management (PBM) programs. Additionally, the Clinical Grievance and Appeals Pharmacist will develop and maintain appropriate clinical, evidence-based documentation that supports PBM programs. The primary functions involve ensuring that Navitus can provide clinically sound programs and medications in the most cost-effective manner and utilize technology to implement on-line PBM programs.

Is this you? Find out more below!

How do I make an impact on my team?

Responsible for support and input to clinical programs such as Health Management, Drug Utilization Review, Formulary development, and clinical programs to encourage appropriate, high-quality, cost-effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place
• Perform quality reviews of: Prior Authorization forms, denial Language, PA Accel
• Continually monitor the quality and efficiency of the Appeals, Redetermination and Grievance process including coverage criteria, denial language, and communication with prescribers
• Review Grievances, Appeals, Complaints, and Redeterminations following all CMS, state, client, and Navitus standards
• Provide input to clinical content of new programs and for maintenance of existing programs
• Participate in audits, on-site or remote audits, as a clinical subject matter expert
• Responsible for supporting/providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee
• Learn and understand the up and downstream processes related to grievances and appeals
• Contribute to the management of grievance and appeal resources/materials
• Other duties as assigned

What our team expects from you?

• A minimum of a bachelor's degree in Pharmacy or Pharm D
• Current unrestricted licensure as an RPh in the State of the home office of the pharmacist, or the ability to gain reciprocity within 4 months of employment is required
• Preferred experience is a minimum two years of clinical experience, or clinical or managed care pharmacy practice residency
• Knowledge of PBM industry, formulary management, utilization review, pharmacy claims and managed care principles and practices desired
• Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline) preferred
• Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences
• Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
• Strong attention to detail to assure projects are clinically, editorially, and systems accurate and can be operationalized
• Proficiency in MS Word, Excel, and Power Point including tables, charts and figures preferred
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees