Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.

Your Impact

• Maintain updated knowledge of the Oregon Administrative Rules (Medicaid) governing coverage determinations.
• Utilization Management (UM) review for medications covered by OHP. This includes review and clinical determination for prior authorization requests and appeals. Assist with utilization review quality initiatives including quality check process and inter-rater reliability testing.
• Effectively navigate and apply the Health Evidence Review Commission Prioritized List of Health Services.
• Evaluate the cost and effectiveness of proposed/delivered services before, during, and after claims payment. Analyze claims data with consideration to medical necessity, the quality of care, and the appropriateness of the delivery of care, and covered benefits.
• Participate in the UHA Interdisciplinary Care Team meetings.
• Assist in formulary management, including submission of benefit configuration change (BCR) requests to PBM.
• Assist in preparing drug monographs and other materials for Pharmacy and Therapeutics Committee.
• Assistin developing clinical criteria related to the management of the prescription drug benefit and certain medical injectables covered under the medical benefit.
• Assist with Medical Management program development and communication of outcomes.
• Complete Medication Management program daily responsibilities including completing comprehensive medication therapy management, targeted medication therapy management, medication reconciliation and follow up activities such as contacting members, pharmacies, and providers. 
• Educates and counsels patients regarding medication therapies under the supervision of a licensed pharmacist.
• Assist other departments in coordinating medication services for members by answering questions and resolving identified barriers.
• Educate members and practitioners about the health plan benefit structure and relevant rights and responsibilities.
• As needed, work with the OHP Grievance and Appeals coordinator when they receive calls from a member or the member’s representative regarding concerns about the care being provided.
• Assisting pharmacies as needed to ensure timely dispensing of medications.
• Assist with process-improvement, workflow development, and policy and procedure creation and review.
• Perform other duties as assigned by management needed to help drive our vision, fulfill our mission, and abide by our organization’s values. 

• PharmD degree from an accredited institution.
• Current Oregon Board of Pharmacy license or equivalent state licensure. 
• Prior experience in quality improvement and population health management preferred.
• 2 years working in a clinical pharmacy setting and managed care experience strongly preferred. 

• Exceptional written, verbal, and interpersonal communication abilities, suitable for interactions with various stakeholders. 
• Superior critical thinking and time management skills for efficient workload organization. 
• Clean record with no suspension, exclusion, or debarment from federal health care programs. 
• Familiarity with Oregon Health Plan, Oregon Administrative Rule, and Medicare Part D regulations. 
• Advanced data analytics proficiency, capable of independent reporting. 
• Understanding of quality improvement principles and ability to lead related initiatives in population health management. 

Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.