Clinical Pharmacy Review Specialist

Now hiring a Clinical Pharmacy Review Specialist

The Clinical Pharmacy Review Specialist II works under the direct supervision of a Clinical Pharmacist within the Pharmacy Services Department.
This position is responsible for providing clinical support for the Fluent Health Pharmacy Services Department surrounding clinical case review submissions. This includes preparing and researching clinical data for coverage determinations, prior authorizations, direct member reimbursement, point of sale claims processing issues and appeals and grievances. The Clinical Pharmacy Review Specialist II will serve as a trainer and mentor for Clinical Pharmacy Review Specialist I and Pharmacy Benefit Technicians.

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

Full Time - Exempt: No
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

• GED or High School diploma is required.
• Clinical Pharmacy Review Specialist I is a pre-requisite with a minimum of 1 year experience.
• PTCB Certification (Pharmacy Technician Certification Board
• License and Certification must be in good standing

• Technical review of prior authorization (drug and utilization management) requests within the pharmacy claims processing system that includes coverage determination request, chart notes, and/or relevant clinical information based on defined criteria within the scope of approved protocols and decision trees.
• Completes documentation review and requests additional information from prescribing physicians to establish medical necessity and forwards to clinical pharmacists for second level review.
• Ability to apply critical thinking skills and use reference documents, clinical criteria, policies and procedures and desktop procedures to complete tasks
• Assign, enter and interpret submitted documentation regarding prior authorization requests into appropriate claims processing system.
• Ability to communicate information to members, providers, pharmacists and pharmacy staff on issues related to benefit coverage, formulary, non-formulary criteria, or respective policies and procedures.
• Knowledge of drug nomenclature, basic pharmacology, dosage calculations, units of measure, prescription filling techniques, prescription documentation requirements, pharmacy laws and regulations, basic managed care pharmacy principles and insurance coverage issues.
• Knowledge of Pharmaceutical products, including oral, injectable, infusion products and chemotherapy drugs.
• May perform activities that require evaluation or interpretation of information related to drug administration and treatments.
• Ability to analyze rejected pharmacy claims and identify resolution for successful claims submission and processing while demonstrating attention to detail, patience, professionalism and compassion while handling difficult customers and situations.
• Ability to perform activities that require evaluation or interpretation of information related to drug administration and treatments.
• Assist Clinical Pharmacist in review of Members medication regimen and assist in Medication Therapy Management.
• Ability to meet established deadlines timely, accurately and with a sense of urgency while following strict guidelines to ensure all work meets regulatory standards for accuracy, timeliness, quality and in compliance with federal, state and accreditation regulations.
• Responsible for knowing and interpreting pharmacy and medical benefits.
• Ability to process and resolve pended medical claims and perform pharmaceutical pricing calculations for reimbursement for claims payment.
• Knowledge of Health care coding systems such as ICD 9 CPT and HCPCS.
• Responsible for researching, gathering supporting documentation and presenting completed pharmacy research files along with recommendations for resolution to the Complaint Management Coordinator within the internal timeframes to remain in compliance with regulatory requirements for pharmacy appeals, pharmacy grievances and or pharmacy complaints.
• Ability to utilize knowledge and experience to analyze pharmacy and medical claims for drugs/pharmaceuticals with utilization management edits
• Assist with special projects and or assignments designated by the Pharmacy Management Team or Team Lead.
• Demonstrates the ability to serve as a mentor to Clinical Pharmacy Review Specialist I and Pharmacy Benefit Specialist roles.

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.