Director Clinical UM Pharmacists
West Sacramento CA 95799 USPS
Job DescriptionProvides oversight for policy implementation and utilization management services. Develops and sustains an interface with client forums, facilitates the delivery of appropriate care and contributes to the development of the clinical mission of the business, including the development, implementation, and evaluation of clinical programs.
- Directs the utilization review process and oversees the quality of utilization determinations.
- Responsible for the quality of the utilization review determinations.
- Develops and implements a utilization management program and action plan.
- Oversees the appeals process. Responsible for the development of the appeals procedures.
- Continuously reviews staff resources to meet contractual service levels.
- Ensures compliance with clinical goals through regular monitoring of center performance.
- Evaluates the effectiveness of the clinical program and modifies programs as needed to achieve desired results.
- Provides clinical leadership, oversight, and consultation for Quality Improvement (QI) Program and the Utilization Management (UM) Program including monitoring effectiveness and compliance with goals, prevention programs, network development and management, quality of care concerns and adverse incidents, medical practice of network or sub-capitated providers, clinical service delivery system, coordination with After Hours Team and oversight of clinical appeals.
- Works collaboratively with QI on the development and implementation of QI activities, UM and QI program descriptions, evaluations, and work plans.
- Implements and interprets pharmacy policy for the contact center, including but not limited to Medical Necessity Criteria and Clinical Practice Guidelines.
- Recruits, trains, supervises, mentors, oversees and evaluates the quality of clinical staff and physician advisors.
- Ensures adequate physician advisor resources.
- Potentially makes outbound or takes inbound telephone calls to assist in various aspects of patient care and/or product distribution to/from practitioners, members, and pharmacies. These calls include, but are not limited to, comprehensive medication reviews, targeted medication reviews, call to practitioners about product awareness, and prior authorizations.
General Job Information
TitleDirector Clinical UM Pharmacists
Job FamilyPharmacy Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date12/26/2019
Date Requisition Created12/26/2019
EducationPharmD: Pharmacy (Required)
License and Certifications - RequiredPharmD - Doctor Of Pharmacy, State Licensure - Pharmacy
License and Certifications - Preferred
Other Job Requirements
- Pharmacy Benefits Management (PBM) experience required.
- Strong drug product and clinical pharmacy knowledge.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
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