Aetna Prior Authorization Clinical Pharmacist in Houston, Texas

Req ID: 45516BR

POSITION SUMMARY

The position will perform clinical review of Medicare Part D prior authorization requests, coordinate the distribution of clinical drug information, and educate providers and staff regarding the appropriate use of pharmaceutical treatment regimens. In addition, the position will support the clinical pharmacy team, supporting quality initiatives as well as other projects as needed by the line of business.

Fundamental Components:

The position will perform clinical review of prior authorization requests, coordinate the distribution of clinical drug information, and educate providers and staff regarding the appropriate use of pharmaceutical treatment regimens. In addition, the position will support the clinical pharmacy team, supporting quality initiatives as well as other projects as needed by the line of business.

Performs clinical review of prior authorization requests. Utilizes clinical experience and skills in a collaborative process to apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render appropriate coverage determination. Monitors prescribing habits of participating physicians. Makes recommendations to physicians to improve medication regimens as appropriate.

  • Improves quality of service to members by developing programs to provide optimal pharmacy care to patients, participating in dispute resolution of drug utilization review, measuring and documenting improvements in patient care, and/or improving claim adjudication for proper provider reimbursement.

  • Acts as "subject matter expert" for clinical pharmacy issues (i.e., appeal, fraud, cognitive services, drug reviews, and education). Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Educates providers and staff regarding the appropriate use of pharmaceutical treatment regimens. May develop and maintain training documents for staff development.

  • Supports the Pharmacy and Therapeutics Committee function. Collaborates with other medical personnel in developing treatment guidelines and demonstrates the impact of these guidelines. May participate in formulary development and management.

  • Performs other duties as required.

    BACKGROUND/EXPERIENCE:

    Current unrestricted state license required.

    Previous (1-3 years) clinical pharmacy experience required.

    Managed care experience preferred.

    Understanding of medical and pharmacy terminology.

    Knowledge of clinical program components, formulary designs, and prescription benefit trends.

    EDUCATION

    The highest level of education desired for candidates in this position is a Doctor of Pharmacy.

    LICENSES AND CERTIFICATIONS

    RPh or Pharm.D degree; Required

    FUNCTIONAL EXPERIENCES

    Functional - Communications/Provider communications/1-3 Years

    Functional - Customer Service/Customer Service - Pharmacy/1-3 Years

    Functional - Clinical / Medical/FE Clinical coverage & policies/1-3 Years

    TECHNOLOGY EXPERIENCES

    Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

    Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User

    ADDITIONAL JOB INFORMATION

    This can be a telework position for candidates with a strong clinical/technical knowledge base and independent problem-solving skills. Pharmacist can have an RPh or Pharm.D degree.

    Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

    We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

    Together we will empower people to live healthier lives.

    Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

    We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

    Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

    Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Job Function: Health Care