Job Title: Pharmacist - Utilization ManagementJob DescriptionThis position will serve as the expert on clinical issues within the team, working closely with the Director of Pharmacy and other staff pharmacists. The role involves collaborating in a culture focused on designing, implementing, maintaining, and measuring pharmacy-related utilization management programs. Responsibilities include the development of workflows, criteria development, and ensuring URAC accreditation is maintained.Responsibilities
Work collaboratively to design, implement, maintain, and measure pharmacy-related utilization management programs.
Develop and maintain clinical criteria and process flows for applicable Utilization Management (UM) programs.
Create and maintain physician fax forms and other communication modes.
Utilize predictive modeling tools to intervene with high-risk members for identified disease states.
Provide clinical updates to internal staff and physician reviewers.
Perform complex research, analysis, and develop recommendations for UM programs and plan design changes.
Provide clinical oversight of the first-level review process.
Perform clinical support for Pharmacy Technicians and other staff.
Utilize reporting tools to create efficiencies by reviewing medical and pharmacy claims data.
Support physician reviewers with necessary information to efficiently review non-approvable claims.
Develop Decision Tree review processes when applicable.
Ensure URAC accreditation is maintained by working with internal staff.
Measure quality assurance reporting, turnaround time for urgent and non-urgent reviews, and perform quantitative assessments of UM reviews by program.
Essential Skills
Pharm.D degree.
Nebraska Pharmacy License (residency in Nebraska not required).
Experience with prior authorization processes.
Knowledge of insurance verification, medical terminology, and medical billing.
Familiarity with pharmacy-related utilization management programs.
Data entry and medical claims review skills.
Experience in retail pharmacy and insurance.
Additional Skills & Qualifications
Certified Pharmacy Technician (Cpht) certification.
Experience in Medication Therapy Management (MTM).
Strong analytical and research skills.
Ability to work collaboratively in a team environment.
Excellent communication skills, both written and verbal.
Work EnvironmentThis is a 100% remote role with a shift of 8am-5pm, Monday to Friday. This position offers a great opportunity for a pharmacist looking to transition from a clinical setting to a remote role.Pay and BenefitsThe pay range for this position is $60.00 - $70.00/hr.Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave)Workplace TypeThis is a fully remote position.Application DeadlineThis position is anticipated to close on Feb 26, 2025.About Actalent Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.Diversity, Equity & Inclusion At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:
Hiring diverse talent
Maintaining an inclusive environment through persistent self-reflection
Building a culture of care, engagement, and recognition with clear outcomes
Ensuring growth opportunities for our people
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email [email protected] (%[email protected]) for other accommodation options.