Clinical UM Pharmacist, NY License Required

HealthFirst · Remote, United States

The Clinical UM Pharmacist is a dynamic position responsible for the review of prior authorizations for medications requested under the medical benefit. Additionally, the Clinical UM Pharmacist is responsible for developing clinical criteria, medical policies for provider administered medications, review of monthly report for quality assurance, and staying current with literature, evidence-based medicine, and trends in medicine. The Clinical Pharmacist works directly with prescribing physicians and Medical Directors to discuss clinical rationale for review decisions.

Monitor and review prior authorization requests for medications
· Calculate appropriate billable units based on dosing, indication, weight, BMI and other clinical considerations
· Develop clinical criteria and medical policies for the review of medications
· Ensure all clinical criteria is in compliance with Center of Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH)
· Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
· Perform and present drug utilization reviews (DUR) on medical benefit medications to assess clinical appropriateness, safety, and cost-effectiveness
· Ensure prior authorization reviews are conducted in timeframes set forth by CMS and/or NYSDOH
· Review monthly reports and present on trends, ideas for efficiency/innovation, and medical spend
· Pharmacy degree from an accredited school of pharmacy
Minimum of 1 year experience conducting prior authorization reviews
Strong clinical knowledge of pharmaceuticals and disease states in order to conduct prior authorization reviews
Strong clinical writing and verbal skills
Knowledge of specialty pharmaceuticals and billing practices in the medical and pharmacy benefits
Passion for learning, promoting the profession of pharmacy, and interest in growing skills in a dynamic environment with various opportunities
Knowledge of regulations of the Centers for Medicare and Medicaid Services including but not limited to National and Local Coverage Determinations.
PC Skills with Microsoft Outlook, Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables).
Regulatory or Compliance activities:
Assists in regulatory and compliance audits for all plans. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.
If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to

reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.