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PBM Medical Director
Date:
Aug 17, 2022
Location:
Any city, IL, US, 99999
Req ID:
10867
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