This position is responsible for providing strategic leadership and development for all clinical aspects and pharmacist roles within the Clinical Review department. This position is responsible for the strategic leadership of Clinical Review . Overall responsibilities also include the technical and clinical operational facets of Clinical Review.
• Oversee the clinical and operational aspects of the Clinical Review pharmacist team. Responsible for meeting quality and timeliness goals in the Clinical Review process.
• Oversee the Special Handling Unit for Clinical Review. Determine direction of the unit and measures of success. Responsible for overall ROI on the unit. Provides direction to leaders within the unit to measure and continually improve process and results
• Develop and manage department budgets, staff goals and objectives, project plans and resource allocations. Responsible for cost management / containment and cost metrics, including productivity standards and expense management and quality case outcomes.
• Responsible for ensuring SOPs are compliant with all applicable regulations. Partners with Compliance to serve as the representation of the Clinical Review department with regard to delegated clinical services and with respect to URAC, NCQA, HIPAA, Department of Labor, and CMS requirements
• Work with Senior Director and/or direct reports to establish and maintain an environment that encourages teamwork and ethical behavior. • Provide strategic leadership and direction to the teams supporting the clinical review process. Provide clinical expertise in the support of volume and staffing forecasts for the Clinical Review Department.
• Represent Clinical Review in Client and internal senior leadership meetings. Participate in Sales discussions with Clients. Serve as the Prior Authorization clinical expert on client implementations. Works directly with Clients in addressing concerns raised with Clinical Review
• Key internal partner on cross-company initiatives and leads joint Prime/client workgroups related to clinical aspects of the clinical review process.
• Accountable for consultation, facilitation and resolution of issues relating to the clinical review process for internal and client constituents.
• Direct the development and implementation of a Quality Assurance and Training program that monitors and provides effective training and coaching for Pharmacist development and monitors the clinical aspects of the process.
• Evaluate results of inter-rater reliability reviews to identify trends and recommend changes to clinical criteria or process to ensure consistent and high quality reviews.
• Hire, coach, mentor, develop and manage staff
• Other duties as assigned
• Bachelors of Science (BS Pharmacy) degree or Pharm D • 5+ years of clinical experience • 7 + years management experience • Eligible for licensure as pharmacist in appropriate states • Current MN pharmacist license • Previous experience managing high volume operational units
• Excellent oral and written communication skills • Previous managed care or clinical pharmacy experience, including Medicare or other government programs • Demonstrated comfort level with the unique complexities of all of the various UM clients and programs • Ability to work under pressure and within strict timeframes • Action oriented, ability to effect change • Ability to manage multiple projects and conflicting priorities
Prime Therapeutics' fast-paced and dynamic work environment is ideal for proactively addressing the constant changes in today's health care industry. Our employees are involved, empowered, and rewarded for their achievements. We value new ideas and work collaboratively to provide the highest quality of care and service to our members.
If you are looking to advance your career within a growing, team-oriented, award-winning company, apply to Prime Therapeutics today and start making a difference in people's lives.
We are proud to be an Equal Opportunity/Affirmative Action Employer M/F/D/V. We maintain a drug-free and tobacco-free workplace and perform pre-employment substance abuse testing.