Clinical Advisor

Job Summary: The Clinical Advisor is responsible for utilizing pharmacy acumen, medication expertise, and healthcare payer knowledge related to drug‑related prior authorization requirements and medication guidelines to support PA operations (in completing PA reviews), PA technology and automation, consultation on evidence‑based guidelines and pharmacy policy, reporting and analytics, and quality management programs. The Clinical Advisor will collaborate with a team of pharmacy technicians and pharmacists in Pharmacy Operations Job Responsibilities (but not limited to): Serves as a subject matter expert in the development and maintenance of drug formularies and clinical programs. Works with stakeholders to understand client’s product‑specific requirements and configuration needs and translate them into technical design specifications and data flow for development, coding, and configuration. Coordinates activities as part of the Formulary Development and Maintenance team and recommends measures to improve performance and efficiency. Manage operations of the Pharmacy & Therapeutics (P&T) Committee including scheduling drug class reviews, reviewing new branded agents, coordinating internal/external membership, documenting P&T minutes, and preparing and organizing P&T files. Conducts and evaluates research necessary for the development of utilization management strategies. Performs clinical reviews of PA, Step Therapy, Quantity Limit, and all other pharmacy utilization requests in accordance with quality, timeliness, and efficiency standards. Performs coverage determinations and appeals requests according to criteria guidelines and in compliance with all state and federal regulations, including Medicare and Medicaid Takes calls from internal and external stakeholders as it pertains to the PA process, answering in a timely, accurate and professional manner. Develops and implements clinical utilization criteria for new market entries and market updates utilizing evidence‑based medicine principles. Makes strategic recommendations including benefit design and formulary analysis, provision of clinical drug information, Pharmacy & Therapeutics support and participation, rational drug formulary positioning, online system edits and restrictions, ongoing clinical product evaluations, and client pharmacy benefit utilization and performance trends as required. Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical, financial, and operational effectiveness and quality. Supports Fraud, Waste and Abuse (FWA) program system oversight and communicates any suspected fraud discovered. Education and/or Training: Bachelor’s degree in pharmacy or related fields required. Doctor of Pharmacy (PharmD) degree from an ACPE accredited college is preferred. Managed Care or Clinical Residency program residency highly preferred. Professional Experience: At least 1 year of recent managed care experience in a PBM or health plan setting is preferred. Experience with Medicare Part D highly preferred. Expert knowledge of the principles and practices of pharmaceutical science, a working knowledge of managed care and policy development as well as working knowledge of state and federal controlled substances and related laws, rules, and regulations. Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology. Licenses/Certifications: Registered and in good standing with the Board of Registration in Pharmacy. Active, non‑restricted pharmacist license. #J-18808-Ljbffr Nirvana Health Ltd.