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PBM Clinical Prior Authorization Pharmacist

Date: Sep 27, 2021

Location: Conway, AR, US, 72034-9501

Company: Gainwell Technologies LLC

As part of the Gainwell clinical pharmacy practice group, the clinical prior authorization pharmacist facilitates efforts in the development of medical pharmacy solutions programs including PA criteria development and coordination of Pharmacy and Therapeutic Committee (P&T) and DUR Board meeting presentations. They work with the clinical practice group to analyze and review drugs and drug classes to inform clinical PA criteria, DUR interventions, utilization controls, and PDL recommendations. They will also work with the system teams in implementing, updating, and maintaining edits, audits, and utilization management configurations in the Pharmacy Services Module.

Job Functions:

  • Prior Authorization Criteria Development:  Evaluate drug and drug class reviews based on sound evidence-based research and processes widely accepted by the medical profession. Ensuring evidence summaries inform the recommendations for management of the preferred drug list (PDL) and clinical prior authorization (PA) criteria. Using appropriate methods that support the principles of high-quality evidence-based medicine.  Develop clinical PA criteria recommendations and documents to present to P&T and/or DUR Board.
  • Providing a thorough review of the clinical and pricing data to assist the P&T Committee or DUR Board in reviewing the Gainwell clinical criteria and PDL recommendations to make coverage and PDL placement decisions.
  • Work with the Gainwell prior authorization teams and call centers to evaluate proposed prior authorization criteria prior to P&T meetings and develop processes and procedures in implementing prior authorization reviews and decisions.
  • Operations:  Contributes to the success of the operations of the pharmacy program by assisting with the implementation and management of both written and verbal communications to physicians and prescribers and maintenance of the edits and data elements that support the edits.  Is available for consultation on pharmacy-related questions and issues for others within the organization.  Updates and maintains program engine, coding, consultation sheets and outreach program as needed.
  • Medical/Clinical:  Upholds clinical integrity of pharmaceutical solutions by staying up to date on medication information, contributing to the identification of pharmacy program best practices, collaborating with Medical Directors and clinical practice group, and providing pharmacy expertise within the organization.