Clinical Pharmacist - Appeals and Operations - remote
Overview
About us:
Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.
Brief summary of purpose:
- Review and provide clinical decisions/recommendations for provider/member submitted appeals and grievances for medically administered medications as well as pharmacy related medications and items for all lines of business.
- Analyze pharmacy data (appeal approval/denial rates, claims, clinical, formulary, financial, etc.) to assist with UM development.
- Assist with formulary development for all lines of business.
- Provide clinical assistance to pharmacy staff for daily operations.
Responsibilities
Primary Job Responsibility
- Responsible for reviewing and providing clinical decisions/recommendations for provider/member submitted appeals and grievances for medically administered medications as well as pharmacy related medications and items for all lines of business.
- Collaborate with the Appeals & Grievance Department, Medical Directors, and Prior Authorizations vendors.
- Maintain turnaround times for all appeal and grievance reviews.
- Review appeal/grievance requests per plan-specific criteria, MassHealth-developed criteria, National Coverage Determinations, and Local Coverage Determinations, Evidence of Coverage, Member Handbooks.
- Follow regulatory rules and processes for Massachusetts, CMS, Medicaid, state Connector programs.
- Consult with internal and external stakeholders as needed.
- Consult with providers.
- Participate in managing clinical issues resolution; work with medical providers and vendors to coordinate and resolve member issues.
- Provide recommendations, as appropriate, to update current prior authorization criteria due to appeals and grievance data.
- Assist with formulary and criteria development for all lines of business.
- Participate in general drug information support for internal and external clients.
- Provide clinical assistance to pharmacy staff for daily operations.
Qualifications
Qualifications requirements
Education
RPH or Pharm D
License
Current license to practice as pharmacist in Massachusetts without restriction
Experience
- 3 years, preferably with at least 1 year in a managed care environment; 1-2 years professional experience practicing as a clinical pharmacist.
- Recent experience related to member and/or provider appeals and drug coverage determinations is a plus.
- Able to evaluate clinical pharmacy data, coverage criteria and drug monographs.
- Able to understand and use computer databases, EMRs, Excel, Word, PowerPoint and others.
- Able to write and orally communicate clinical decisions to physicians and other healthcare personnel.
- Excellent communication skills, coordination, and planning skills along with an ability to interact with a variety of audiences to build collaboration and consensus.
Pay Range Disclosure: In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $ 135,000-$145,000 annually which reflects what we rea