Clinical Advisor

Company Description

nirvanaHealth is a trailblazing provider of cloud-native Payer and pharmacy benefit manager (PBM) platforms, leveraging robotic process automation (RPA) to simplify healthcare operations. The company's state-of-the-art systems integrate medical, pharmacy, and behavioral services to reduce administrative and medical costs while improving quality. By combining deep healthcare domain expertise with proven platform development capabilities, nirvanaHealth is at the forefront of healthcare automation. Their innovative solutions are transforming the Payer and PBM industries.

Job Summary: 

The Clinical Advisor is responsible for utilizing pharmacy acumen, medication expertise, and healthcare 

payer knowledge related to drug-related prior authorization requirements and medication guidelines to 

support PA operations (in completing PA reviews), PA technology and automation, consultation on 

evidence-based guidelines and pharmacy policy, reporting and analytics, and quality management 

programs. The Clinical Advisor will collaborate with a team of pharmacy technicians and pharmacists in 

Pharmacy Operations.

Job Responsibilities (but not limited to): [PHARM Core 25 (d)]

• Serves as a subject matter expert in the development and maintenance of drug formularies and 

clinical programs. 

• Works with stakeholders to understand client’s product-specific requirements and configuration 

needs and translate them into technical design specifications and data flow for development, 

coding, and configuration. 

• Coordinates activities as part of the Formulary Development and Maintenance team and 

recommends measures to improve performance and efficiency. 

• Manage operations of the Pharmacy & Therapeutics (P&T) Committee including scheduling drug 

class reviews, reviewing new branded agents, coordinating internal/external membership, 

documenting P&T minutes, and preparing and organizing P&T files.

• Conducts and evaluates research necessary for the development of utilization management 

strategies. 

• Performs clinical reviews of PA, Step Therapy, Quantity Limit, and all other pharmacy utilization 

requests in accordance with quality, timeliness, and efficiency standards.

• Performs coverage determinations and appeals requests according to criteria guidelines and in 

compliance with all state and federal regulations, including Medicare and Medicaid.

• Takes calls from internal and external stakeholders as it pertains to the PA process, answering in 

a timely, accurate and professional manner. 

• Researches and appropriately responds to PA guideline coding and rationale questions.

• Develops and implements clinical utilization criteria for new market entries and market updates 

utilizing evidence-based medicine principles.

• Makes strategic recommendations including benefit design and formulary analysis, provision of 

clinical drug information, Pharmacy & Therapeutics support and participation, rational drug 

formulary positioning, online system edits and restrictions, ongoing clinical product evaluations, 

and client pharmacy benefit utilization and performance trends as required.

• Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical, 

financial, and operational effectiveness and quality. 

• Provides support for internal and external audits and surveys. 

• Supports Fraud, Waste and Abuse (FWA) program system oversight and communicates any 

suspected fraud discovered. 

• Assures compliance with RxAdvance policies and procedures. 

• Has a thorough understanding of and performs in compliance with the current URAC and NCQA 

standards applicable to the position. 

• Stays abreast of new regulations to ensure regulatory compliance of PA guidelines.

• Maintains privacy and confidentiality in all PA or appeal request interactions.

• Follows all state and federal regulations applicable to PBM operations and utilization 

management.

• Other duties as assigned. 

Qualifications: [PHARM Core 25 (a) (b) (c)]

1. Education and/or Training:

• Bachelor’s degree in pharmacy or related fields required. 

• Doctor of Pharmacy (PharmD) degree from an ACPE accredited college is preferred. 

• Managed Care or Clinical Residency program residency highly preferred. 

2. Professional Experience:

• At least 1 year of recent managed care experience in a PBM or health plan setting.

• Experience with Medicare Part D highly preferred. 

• Must have a regard for confidential data and adherence to corporate compliance policy. 

• Expert knowledge of the principles and practices of pharmaceutical science, a working 

knowledge of managed care and policy development as well as working knowledge of state and 

federal controlled substances and related laws, rules, and regulations. 

• Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology. 

3. Licenses/Certifications:

• Registered and in good standing with the Board of Registration in Pharmacy.

• Active, non-restricted pharmacist license. 

4. Specialized Skills:

• Strong clinical review competency. 

• Requires a high degree of initiative and excellent judgment to make decisions regarding clinical 

pharmacy issues in an extremely complex and often politically charged environment. 

• Requires excellent analytical skills necessary for program implementation, maintenance and 

enhancement and ability to analyze, assess and monitor physicians' prescribing trends and drug 

utilization patterns for clinical appropriateness and cost-effectiveness with the Plan's operations 

and goals. 

• Highly developed oral/written communication skills, self-motivation, and ability to work 

independently with minimal supervision are necessary. 

• Must be flexible and able to constantly review and reset priorities, often daily, and to handle 

multiple projects simultaneously. 

• Must be able to appropriately identify emergency situations and follow through with the 

appropriate protocol. 

5. Technical Skills:

• Strong PC skills; MS Word, Excel, Access, and Power Point.

6. Additional Considerations:

• Applicants must be able to pass a background investigation as all offers are pending successful 

completion of background check per the company policy. 

Physical and Mental Requirements: 

1. Physical Activities:

• Some travel may be required. 

2. Mental Activities: 

• General mental activity related to job duties.