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TX PBM Medical Director

Date:  Sep 8, 2022

Any city, TX, US, 99999

Req ID:  14059


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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