MS Prior Authorization Pharmacist

Summary

As ​MS Prior Authorization Pharmacist at Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve — a community’s most vulnerable. Connect your passion with purpose, teaming with people who thrive on finding innovative solutions to some of healthcare’s biggest challenges. Here are the details on this position.

The account Pharmacist will work directly with the account Pharmacy Manager and the state Pharmacy Program Director to operate the Medicaid prescription drug program within the state budget and according to legislative requirements and laws.   

Your role in our mission

Clinical evaluation of medication therapy 

Review Prior Authorization request from medical professions using the PDL Criteria  

Peer to Peer discussions with medical providers to discuss Prior Authorization reviews. 

Consultations/Interventions: work with Gainwell staff in contacting prescribers needing consultation to provide clinical information on prescribing practices that have been identified as outliers.  Reviews prior authorizations data and determines opportunities for interventions. 

Operations: Contributes to the success of the Clinical Call Centers and Prior Authorization department by assisting with the implementation and management of both written and verbal communications to members and physicians.  

Available for consultation on pharmacy-related questions and issues for others within the organization.  

Providing clinical input to call center agents handling provider and pharmacy calls 

Quality Improvement: Contributes to program improvements by using continuous quality improvement processes, by being proactive in identifying improvement opportunities and by contributing to on-going consultation and collaboration with product leaders. 

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, Clinical Pharmacist, and Clinical Specialty Pharmacist to provide pharmacy expertise. 

Drug Review: Provides clinical input during the weekly drug file updates, making recommendations on applying utilization controls  

Providing pharmacy knowledge needed for the account Medicaid Drug Rebate Program operations. 

Assisting the state with pharmacy audits using claim details from the system  

Providing ongoing training to pharmacy providers as needed 

Producing annual reports as well as other executive administration duties as they pertain to the State pharmacy program. 

What we're looking for

Registered Pharmacist with respective State Licensure 

Resident of Mississippi 

PharmD (preferred) or Bachelor of Pharmacy degree 

At least two (2) years of experience working in a pharmacy setting or pharmacy benefit management system. 

Knowledge of Medicaid at the state and/or federal level. 

Knowledge of pharmacy-related aspects of Medicaid. 

Working knowledge of HIPAA regulations and requirements. 

Knowledge, Skills, Abilities 

Ability to communicate succinctly and accurately in both written and verbal English. 

Ability to perform clinical reviews using relevant compendia and clinical trial data. 

Managed care pharmaceutical service experience a plus. 

Strong research and implementation skills in practical settings. 

Analytical skills which can translate into practical and pragmatic recommendations. 

Strong team orientation with respect for all members. 

People skills are essential that allow for the successful consultation and collaboration with internal and external stakeholders who do not directly report to this job 

Excellent organizational, written, and oral communication skills 

Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) 

Highly skilled with Microsoft office products and ability to quickly learn proprietary systems. 

Proficient with work organization and problem resolution skills. 

What you should expect in this role

• Opportunities to travel through your work (0-10%)
• Must be licensed and live in MS