Create and Maintain Clinical Criteria for applicable Utilization Management (UM) programs
Develop and maintain clinical criteria; Develop and maintain criteria process flows; Develop and maintain physician fax forms and other modes of communication
Provide clinical updates as necessary to internal staff and physician reviewers
Performs highly complex research, analysis and develops recommendations for UM programs & plan design changes
Responsible for Operational workflows and Completion of UM reviews
Clinical oversight of first level review process; Clinical review of utilization management reviews; Perform clinical support for Pharmacy Technician and other staff
Utilize reporting tools to create efficiencies by reviewing medical and pharmacy claims data
Develop Decision Tree review process when applicable
Maintain URAC accreditation
Measure quality assurance reporting, turnaround time for urgent and non-urgent reviews and quantitative assessment of UM reviews by program
Support Medicare Advantage processes, outreach, presentations, and tasks that require clinical direction and support

Doctor of Pharmacy required from Accredited US College of Pharmacy
An active, current, and unrestricted license or certification to practice pharmacy in Nebraska
Experience with PBM operations, Medicare Advantage, and/or clinical program development and maintenance
Managed Care Pharmacy Residency or 3-4 years of experience in Managed Care Pharmacy industry

Clinical Pharmacist

Key skills