Clinical Pharmacist

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Care Management Full Time Montvale, NJ, US

2 days ago Requisition ID: 1299

Clinical Pharmacist-Prior Authorization

EmpiRx Health is the leading clinically-driven pharmacy benefits management company. As the pioneer in value-based pharmacy care, EmpiRx Health puts its customers and members first by enabling them to take control of their pharmacy benefits, healthcare outcomes, and financial results.

We place more emphasis on member care than any other PBM by focusing on health outcomes first. Our pharmacists and clinicians are at the center of everything we do―and our population health solution delivers tailored strategies for our clients. Leveraging our newly launched, AI-powered pharmacy care platform, Clinically, EmpiRx Health’s pharmacists and client experience teams provide the highest quality pharmacy care to our clients and their members. This enables benefits plan sponsors to keep their members healthy, happy, and productive, while substantially reducing prescription drug spending, which has been on an explosive growth trajectory in recent years.

Position Summary:

The Clinical Pharmacist – Prior Authorization ensures clinical prior authorization and appeal determinations are completed in accordance with covered plan design while ensuring clinically appropriate pharmacy care and sustainable clinical savings for clients. This role supports EmpiRx Health’s Population Health Management model through collaboration, evidence-based decision-making, and proactive engagement with providers to drive optimal clinical and financial outcomes.

What You’ll Do:

Clinical Review & Determinations

• Act as a clinical expert on prior authorization review and evaluationin accordance withclinical criteria and covered plan design.
• Conduct thorough evaluations and resolutions of assigned clinical reviews by performing in-depth case analyses and collaborating directly with physicians, in alignment with EmpiRx Health’s Population Health Management framework.
• Perform peer-to-peer reviews with providers as needed or when requested.
• Convey clinical determinations promptly within established turnaround time requirements to prescribers, members, and healthcare professionals following established approval and denial protocols.

Clinical Oversight & Quality Assurance

• Monitor and proactively identify clinical interventions to ensure clinical savings guarantees are met.
• Review and evaluate current clinical literature to support decision-making and provider recommendations.
• Participate in continuous quality improvement initiatives to streamline review processes and enhance member care.
• Stay informed about EmpiRx Health formulary changes, clinical programs, and internal policies and protocols.
• Provide guidance and support to members, providers, and healthcare professionals regarding clinical inquiries.
• Collaborate with clinical technicians and Clinical Account Executives to facilitate review requests, resolve escalations, and answer inquiries.
• Act as a clinical resource for internal staff, supporting staff training and development as needed.
• Collaborate cross-functionally with internal teams for claim/data review, clinical interventions, and provider, member, or client support as required.
• Proficiently utilize pharmacy management software for documentation and communications.
• Proficiently utilize Microsoft Office tools to support analysis and reporting.
• Utilize external clinical and drug information databases (e.g., IPD, UpToDate,MediSpan) to support reviews, decisions, and awareness of emerging drugs.

Education and Experience:

Education

• Pharm.D. degree from an accredited college of pharmacy (Preferred).

Experience

• Minimum of 3 years of pharmacy experience in clinical, PBM, or managed care settings.
  Prior experience with prior authorization, utilization management, or health plan operations preferred.

Licensure & Certifications

• MTM or other specialty certifications preferred.
• Strong clinical judgment and analytical skills.
• Exceptional written and verbal communication with a comfortability of speaking with providers and medical staff.
• High attention to detail and accuracy in documentation.
• Excellent organizational and multitasking abilities.
• Proficient in Microsoft Office Suite and pharmacy systems.
• Ability to work independently and collaboratively in a fast-paced environment.

Subject to program eligibility, this position qualifies for a robust suite of benefits including:

• Paid Time Off
• a 401(k) program
• Health Insurance including Dental & Vision coverage
• Health Savings Account
• an Employee Assistance Program

EmpiRx Health is an Equal Opportunity Employer

At EmpiRx Health, we wholeheartedly embrace the power of diversity and the magic of inclusion. The kaleidoscope of unique perspectives, backgrounds, and talents fuels our innovation and sets us apart. We're on a mission to build a team as diverse as the world we serve, where everyone is welcome and celebrated. We're not just breaking down barriers; we're actively erasing them to create an environment where opportunity knows no bounds. In unity, we find our strength and invite individuals from all walks of life to join us in our exhilarating journey to shape a brighter, more inclusive future together.

Note: This job description is a general outline of responsibilities and qualifications for the role. Additional duties may be assigned, and the position may evolve to meet the organization's needs.