Under the direction of the Pharmacy Utilization Management (UM) Supervisor, the Clinical Pharmacist is responsible for reviewing, processing and managing the daily caseload of pharmacy prior authorization (PA) requests for coverage determinations (CD), and exceptions. The Clinical Pharmacist ensures timely disposition of reviews for CD and exceptions by adherence to established timeframes. The Clinical Pharmacist consults as required with THP Medical Directors (MD) on prior authorization that fails to meet drug prior authorization (PA) criteria for coverage.
- Performs case reviews in automated prior authorization (Auto PA) tools and guides the case through the entire process to either approval or denial to ensure all coverage determinations and notices are consistent with applicable regulatory and accreditation requirements and turnaround times
- Provides all aspects of clinical support needed to perform drug prior authorization (PA) requests and consults as required with THP Medical Directors (MD) on cases that fail to meet coverage criteria
- Communicates daily with members, providers and other external customers regarding status and disposition of cases
- Oversees and addresses any quality issues with pharmacy technicians and confer with other clinical pharmacist on review questions
- Communicate with UM staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage determinations within timelines developed by all accrediting and regulatory guidelines
- Facilitates communication between Pharmacy UM department and other internal Tufts Health Plan departments by acting as a liaison or committee member on the development or implementation of new programs
- Performs other roles/duties and projects as assigned by the Pharmacy UM Supervisor or Manager
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Founded in 1979, Tufts Health Plan is nationally recognized for its commitment to providing innovative, high-quality health care coverage.