Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)
Position in this function is under general supervision of the Director of Clinical Pharmacy, the Supervisor of Clinical Pharmacy is responsible for completing prior authorization functions as needed for WellMed Managed Care Patients. This position will also work with UM nurses as a Clinical Pharmacist and the Medical management P&T Committee. The Supervisor of Clinical Pharmacy is also responsible to follow processes to improve patient care, outcomes, and quality improvement metrics related to CMS HEDIS/Star ratings. This position will provide clinical, administrative, and leadership support to assigned staff in accordance with policies and procedures.
Manages and evaluates direct report staff including training and staff onboarding
Manages the compliance for Part B Pharmacy prior authorization queues to meet established performance metrics
Provide timely review for WellMed members by processing prior authorization and medical necessity requests for specialty CMS part B medications
Review specialty medication prior authorization requests (i.e. biopharmaceuticals) according to established treatment protocols, clinical criteria, member benefits. and make determinations within the defined turnaround times and meet regulatory requirements
Knowledgeable of current and emerging clinical trends
Active participation in various clinical departmental meetings and forums to improve clinical programs, enhance processes, and share clinical information
Continuously look for ways to streamline and improve workflow
Assist with user acceptance testing for new clinical programs and system enhancements
Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practice specific to specialty pharmacy
Serves as a clinical resource and consultant in all areas of pharmacy and medication management
Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Supports medical management and pharmacy quality initiatives
Follow all policies and procedures related to job
Ensures all direct reports remain up to date and in compliance with all education, training, and regulatory requirements. Develops corrective action plans to address gaps as needed.
Actively participates in process improvement planning and implementation while fostering good communication and collaboration across all affected departments
Assist with routine audits on UM clinical reviews and claims to ensure adherence to CMS and NCQA regulations/guidelines
Assist with gathering, analyzing and interpreting data and metrics to evaluate effectiveness of Enterprise Care & Value Pharmacy programs/initiatives
Assist with the development of policies, procedures, workflows, job aids, and other key documents related to Enterprise Care & Value Pharmacy.
Serves as a subject matter expert (SME) for process/workflow related questions
Assist with the development and implementation of all Enterprise Care & Value Pharmacy projects and initiatives
Performs all other related duties as assigned to meet departmental objectives
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Doctor of Pharmacy degree
Current Pharmacist license to practice in the applicable state or the ability to provide proof of licensure within 90 days from date of employment
2+ years of experience as a Authorization Pharmacist or Clinical Pharmacist
Additional 2+ years of pharmacy leadership experience inclusive of project management/leadership, cross-functional collaboration/work to accomplish initiatives, etc.
Experience working with provider relations, working within various payor environments, and risk management
Proven planning and organizational skills to demonstrate leadership and initiative
Proven solid interpersonal skills. Ability to work independently, as well as a member of a team
Proven solid analytical and PC operation skills
Proven excellent written and verbal communication skills
Proven excellent relationship building skills
Ability to travel as necessary
Board certification by the Board of Pharmacy Specialties (BPS)
Certified Geriatric Pharmacist
Certification in Medication Therapy Management (MTM)
Experience with Medicare guidelines
Fluent in Spanish Language
Physical & Mental Requirements:
Ability to lift up to 10 pounds
Ability to push or pull heavy objects using up to 20 pounds of force
Ability to sit for extended periods of time
Ability to stand for extended periods of time
Ability to use fine motor skills to operate office equipment and/or machinery Ability to properly drive and operate a company vehicle
Ability to receive and comprehend instructions verbally and/or in writing Ability to use logical
reasoning for simple and complex problem solving
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)
WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.