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PBM Medical Director

Date:  Aug 17, 2022

Any city, IL, US, 99999

Req ID:  10867


  • 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

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