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TX PBM Medical Director

Date:  Sep 8, 2022
Location: 

Any city, TX, US, 99999

Req ID:  14059

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.

Your role in our mission


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

What we're looking for

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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