PBM Medical Director

Summary

• Provide clinical expertise, leadership, and oversight to the operations and clinical initiatives that support the Pharmacy Benefit Manager program.  
   
• Act as liaison to client and providers by resolving problems and clarifying medical and healthcare issues.  
   
• Recommend and promote beneficial changes to customer programs to promote access to quality care and control of benefit packages.
   
• Assist in adjudication of medically complicated claims.
   
• The physician is to help with cost containment and utilization review measures to make payment for only those treatments and services that are medically necessary, appropriate, and cost effective. 
   
• The physician will be trained on applicable program criteria and will apply these criteria in utilization management decision-making.  
   
• Provide clinical support to the pharmacy team in activities related to Utilization Management, Population Health, Clinical Outcomes, Quality Improvement, and Health Equity.

Job Description

• Perform reviews of appeals as part of the Utilization Management function for the PBM
   
• Provide oversight to the Utilization Management program as subject matter expert
   
• Analyzing utilization by subpopulation demographics to ensure optimal care for all populations
   
• Analyzing utilization by service areas (service types and geographies) prioritized by ODM for utilization management
   
• Establishing a process for setting thresholds for selected types of utilization (e.g., clinical criteria)
   
• Analyzing Contractor’s performance against standards for timeliness of utilization management decisions
   
• Immediately investigating any identified over- or under-utilization of services in order to determine root cause, corrective action to identified problem areas, and monitoring of data
   
• over time to ensure sustained correction of the problem that led to under-utilization
   
• Evaluating the consistency of the application of UM criteria
   
• Establishing methods to ensure that the UM decision-making process is as efficient and uncomplicated as possible for the member, the prescriber, and the pharmacy
   
• Communicating identified trends to Contractor staff, ODM, ODM-contracted managed care entities, and providers as appropriate.
   
• Participate in Quality Improvement activities
   
• Apply clinical criteria to make determinations related to medical necessity for requested services, medications, and procedures independent of cost-containment efforts
   
• Demonstrate strong oral/written communication skills
   
• Demonstrate the ability to read, understand, and interpret complex regulatory and procedural documents
   
• Demonstrate PC skills
   
• Demonstrate time management and organizational skills
   
• Demonstrate the ability to work independently 
   
• Demonstrate strong analytical skills
   
• Demonstrate the ability to successfully interact with other departments
   
• Provide clinical support to PBM team activities
   
• Population Health
   
• Clinical Outcomes
   
• Health Equity

Job Requirements

• Doctor of Medicine or Osteopathy
   
• Board certification
   
• Unrestricted license to practice medicine
   
• Qualified by education and experience to provide clinical oversight
   
• Post graduate experience in direct patient care
   
• Experience in Utilization Management
   
• Experience in Medicaid programs and administration preferred