Overview

Scope of Responsibilities: Relies on experience and professional judgment to plan and accomplish assigned tasks and goals that meet the clinical needs of ProAct clients and members, including the development, execution, and growth of cost avoidance measures. Responsible for the growth and direction of clinical operations for PBM clients. Manage the prior authorization process to ensure consistency, compliance, and efficiency in process.

Job Summary: Responsible for management of clinical operations including the growth and development of clinical team and clinical offerings.

Responsibilities

• Responsible for managing the prior authorization and appeals process for ProAct members, including administrative responsibilities related to reporting and invoicing
• Responsible for supporting clinical implementation for new ProAct clients
• Responsible for the development, execution, growth, and reporting on cost saving programs for clients based on the review of utilization data and market trends
• Programs include utilization management, mail order/specialty utilization, generic conversion (therapeutic alternatives program), formulary compliance, diabetes/pulmonary disease management, and clinical optimization
• Responsible for supporting other ProAct departments and/or team members as a clinical resource, this includes but is not limited to benefit operations, marketing, sales, account management, and proposal departments
• Assist with client review meetings, performing a review of drug utilization and analysis of claims and trends, articulating what ProAct is doing clinically to support the client in managing their trends
• Responsible for keeping current with changes and trends in the industry and ensuring the communication of this information with member facing teams, partners, vendors, and clients as needed
• Responsible for managing, leading, and holding accountable, the team of clinical pharmacist(s), clinical care coordinator, clinical services specialists, and clerks
• Assist in summarizing and submitting monthly formulary and specialty change updates, coordinating bi-annual client and member communication of changes, and updating member facing marketing material associated with changes
• Ensure compliance to policies and procedures falling under the scope of clinical practice including but not limited to state specific utilization review agent requirements
• Responsible for completing all mandatory and regulatory training programs
• Perform other duties as assigned

Qualifications

Educational Requirements:

• Preferred
• Pharmacy Degree from an accredited College of Pharmacy
• Nursing Degree from accredited College of Nursing
• BS degree in another healthcare-related field

Experience Preferred:

• Preferred:
  • 3-5 Years of experience in a managed care setting
  • 2-3 Years of experience in clinical case management

Special Conditions of Employment:

• Drug test
• Initial and continuous exclusion and sanction/disciplinary monitoring
• Any and all additional eligibility requirements based on the specific position