Prior Authorization Pharmacist

Job Description

Job Description

Let’s do great things, together!

About Moda
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Position Summary
We are currently seeking a skilled and dedicated pharmacist to join our clinical pharmacy team. In this role, you will have the exciting opportunity to focus on the vital prior authorization functions of our work. Your primary responsibilities will involve making coverage determinations and completing appeal requests, using your clinical expertise to provide coverage decisions based on established criteria, guidelines, and specific plan design. By joining our team, you will be part of a dynamic environment where you can make a significant impact on patient care and contribute to the overall success of our healthcare organization. This is FT WFH position.

Pay Range

$103,893.01 - $132,461.48 annually (depending on experience)
*This role may be classified as hourly (non-exempt) depending on the applicant's location. Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Please fill out an application on our company page, linked below, to be considered for this position.

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Benefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education:

1. Current active and unrestricted Oregon Registered Pharmacist license, or eligible for Oregon licensure which is to be obtained within 60 days of hire date
2. Effective communication and interpersonal skills to interact with healthcare providers, internal teams, and external stakeholders
3. Commitment to service, organizational values, and professionalism through appropriate conduct and demeanor always
4. Works well under pressure with frequent interruptions and shifting priorities
5. Follow the company HR policies, Code of Conduct, and all department policies and procedures including protecting confidential company, employee, and customer information

Preferred Skills

1. Doctor of Pharmacy degree (Pharm.D.)
2. Experience in clinical therapeutics for specialty drugs
3. Two to three years of managed care experience

Primary Functions:

1. Evaluate medication requests for coverage (e.g., prior authorization reviews, non-formulary requests, step therapy exceptions), conducting thorough clinical reviews and assessing their compliance with established clinical guidelines, formularies, and policies
2. Provide prior authorization pharmacist coverage for rotating weekends and holidays
3. Provide ad hoc or on call support for urgent medication requests and provide internal pharmacist support to the pharmacy team, appeals unit, and customer services department
4. Perform coverage determination reviews for all lines of business (i.e., commercial, exchange, government) for pharmacy and medical (physician-administered or home infusion) medications
5. Participate in the appeals and grievances process by providing clinical expertise and reviewing medication-related appeals and complaints
6. Complete medical literature evaluation using primary, secondary, and tertiary drug resources to support coverage decision-making and recommendations
7. Perform peer-to-peer reviews with providers when requested
8. Make recommendations on medication edit improvements (e.g., programming) and coverage criteria, based on utilization and findings during coverage determination reviews
9. Provide clear, comprehensive, and timely responses to requests for drug information to members, clients, providers, and internal staff via detailed and thorough documentation within coverage determinations, appeal documentation, and email inquiries
10. Organize workload, set priorities, complete assignments in a timely manner and utilize resources appropriately while complying with department program standards
11. Participate in and support department quality assurance and ongoing improvement practices
12. Remain current on all communications and updated processes relayed through multiple team communication channels and apply to daily duties and responsibilities
13. Support staff training and development as required
14. Review, update, and maintain applicable policies and procedures related to clinical pharmacy services
15. Performs all other related duties as assigned by departmental managers

Working Conditions & Contact with Others

• Remote, office environment, and/or hybrid with extensive close PC and keyboard work, and constant sitting. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business needs. May require occasional travel to conferences or offsite business meetings.
• Internally with Clinical Pharmacy, Analytics, Marketing, Sales & Account Services, Actuary & Underwriting, Healthcare Services, Medicare and Medicaid Programs, Benefits, Legal, Regulatory Affairs, and Compliance. Externally with PBM, medical management vendor, pharmaceutical and biotechnology manufacturers, consultants and benefit managers, clients, providers, and pharmacists.

Together, we can be more. We can be better.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training.

For more information regarding accommodations, please direct your questions to Kristy Nehler & Danielle Baker via our View email address on ziprecruiter.com email.