Careers At HGS

Prior Authorization Pharmacist SME

Job Code : HGS/802
Work@Home

Job Description

Responsible for utilizing pharmacy acumen, medication expertise, and healthcare payer knowledge related to pharmacy prior authorization requirements and medication guidelines to support the prior authorization operations team in completing review on escalations on prior authorization intake requests, answering team queries on prior authorization requests, supporting applicable training content development, assisting with process consulting and improvement, supporting prior authorization technology & automation, consultation on use of pharmacy guidelines, supporting pharmacy prior authorization reporting and analytics, participating in prior authorization quality management process, and providing support for any client, program, and escalated pharmacy questions for identified line of business with emphasis on privacy, accuracy, & meeting all regulatory and compliance timelines.



Principal Duties and Responsibilities:

1.      Utilizing pharmacy acumen, medication expertise, and healthcare payer knowledge related to pharmacy prior authorization requirements and medication guidelines to support the prior authorization operations team in:

a.    Training content relevant to the scope of Prior auth intake

b.     Academy for scaling pharm-techs as needed

c.     Reviewing on escalations on prior authorization intake requests

d.    Answering team queries on prior authorization requests

e.     Supporting applicable training content development

f.      Assisting with process consulting and improvement

g.    Supporting prior authorization technology & automation

h.    Consultation on use of pharmacy guidelines

i.       Supporting pharmacy prior authorization reporting and analytics

j.       Participating in prior authorization quality management process

k.    Providing support for any client, program, and escalated pharmacy questions

l.     Weekly/Monthly client presentations on program updates

m.   Support new RFPs or client presentation for Pharmacy related scope

n.    Provide clinical review support for pharmacy coverage determination as needed

2.      Maintains emphasis on privacy and confidentiality in all case interactions for identified line of business

3.      Responsible for assisting identified line of business to meets all contractual SLAs and applicable regulatory/compliance timelines

 

The above statements are intended to indicate the general nature and level of work being performed by employees within this classification.  They are not intended to be an exhaustive list of all responsibilities, duties and skills required of employees assigned to this job.  Employees in this job may perform other duties as assigned.  In addition to the above, all HGS employees are expected to:

 

* Promote teamwork and cooperative effort.  * Help train and give guidance to other HGS employees.  * Maintain a clean, safe, and unobstructed work area, and practice good safety habits.  * Provide internal and external customers with the highest quality service.

 

 

Minimum jOB Requirements: (Education, Experience, Skills)

 

  • Licensed US Pharmacist with Doctor of Pharmacy (PharmD) degree or other educational equivalent
  • Minimum 2-3 work experience as a US pharmacist with proven productivity and quality
  • Preferable areas of expertise- experience in pharmacy benefit management (PBM), medication prior authorization, or coverage determination
    • Management experience a plus
    • Medical record review experience, preferred
  • Strong communication skills required in both oral, written, and presentation settings

·         Prior experience required in working with pharmacy workflows and associated process improvements

·         Strong technical skills required for learning multiple programs and applicable expertise

o    Expertise as SME in prior PBM platforms a plus

  • Location required: US Onshore or Remote
  • Ability to work independently and follow strict state and NCQA guidelines as well as client policies
  • Strong PC skills required including high level experience with MS Outlook, Word, Excel, and PowerPoint
  • Positive work history required
  • Good ability for reading and written English, pharmacy acumen and medical records review skills

 

 

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