Prior Authorization Pharmacist at Moda Health Portland, OR

Position Prior Authorization Pharmacist – Moda Health. Portland, OR. Position Summary We are a clinical pharmacy team seeking a skilled pharmacist to focus on prior authorization functions. Primary responsibilities include making coverage determinations and completing appeal requests, using clinical expertise to provide coverage decisions based on established criteria, guidelines, and specific plan design. This is a full-time, work-from-home position. Pay Range $52.53 - $66.60 hourly (depending on experience). Actual pay is based on qualifications. Applicants who do not meet the minimum qualifications will be considered for the low end of the range. Please fill out an application on our company page, linked below, to be considered for this position.

Benefits

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K - Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education

• Current active and unrestricted Oregon Registered Pharmacist license, or eligible for Oregon licensure which is to be obtained within 60 days of hire date
• Effective communication and interpersonal skills to interact with healthcare providers, internal teams, and external stakeholders
• Commitment to service, organizational values, and professionalism through appropriate conduct and demeanor always
• Works well under pressure with frequent interruptions and shifting priorities
• Follow the company HR policies, Code of Conduct, and all department policies and procedures including protecting confidential company, employee, and customer information

Preferred Skills, Experience & Education

• Doctor of Pharmacy degree (Pharm.D.)
• Experience in clinical therapeutics for specialty drugs
• Two to three years of managed care experience

Primary Functions

• Evaluate medication requests for coverage (e.g., prior authorization reviews, non-formulary requests, step therapy exceptions) by conducting thorough clinical reviews and assessing alignment with clinical guidelines, formularies, and policies
• Provide prior authorization pharmacist coverage for rotating weekends and holidays
• Provide ad hoc or on-call support for urgent medication requests and support the pharmacy team, appeals unit, and customer services department
• Perform coverage determination reviews for all lines of business (commercial, exchange, government) for pharmacy and medical medications
• Participate in the appeals and grievances process by providing clinical expertise and reviewing medication-related appeals and complaints
• Complete medical literature evaluation using primary, secondary, and tertiary drug resources to support coverage decision-making
• Perform peer-to-peer reviews with providers when requested
• Make recommendations on medication edit improvements and coverage criteria based on utilization
• Provide clear, comprehensive, and timely responses to requests for drug information with documentation in coverage determinations, appeal documentation, and inquiries
• Organize workload, set priorities, and complete assignments in a timely manner while complying with department standards
• Participate in and support department quality assurance and ongoing improvement practices
• Remain current on communications and updated processes relayed through team channels and apply to daily duties
• Support staff training and development as required
• Review, update, and maintain applicable policies and procedures related to clinical pharmacy services
• Performs other related duties as assigned by departmental managers

Equal Opportunity Moda Health seeks to provide equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status, or any other legally protected status. This applies to all terms and conditions of employment including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. For information regarding accommodations, please contact Kristy Nehler or Danielle Baker at [email protected]. #J-18808-Ljbffr Experience: 3 years required