Specialty Pharmacy Case Reviewer

JOB SUMMARY  

In partnership with specific Kaiser Permanente Washington (KPWA) Pharmacy staff, this individual reviews select, new drug starts and may discuss appropriate treatment options with the members’ specialist in the appropriate specialty, consistent with Kaiser Permanente (KP) recommended clinical pathways. Special projects as assigned.

As needed, ensures that requests for coverage are adjudicated using professionally recognized standards and criteria. Requests are reviewed for clinical indications, appropriateness, and compliance with contract language. This is achieved through well documented case review, the consistent application of decision tools, criteria and data collection, and feedback to regional medical directors, program chiefs, individual physicians and care management related to clinical review outcome trends.

PRINCIPAL DUTIES & RESPONSIBILITIES

Responsibility

Description

Professional Competence

• Able to work well with other health professionals (pharmacists, RNs, case managers) to effectively facilitate appropriate specialty level of care for KPWA patients in a variety of care settings.
• Assists in the development of clinical review criteria and programs in the appropriate specialty.

Teamwork and Collaboration   

• Engages in collegial and respectful telephone conversations with physicians and other health care providers who request consultation regarding coverage issues and discuss options for resolution.
• Assists in conversations around advanced therapeutics discussions for therapy.
• Works with the Clinical Guidelines staff, Medical Technology Committee, and Pharmacy and Therapeutics Committee in reviewing requests for new services to determine whether they are medically necessary, effective, or experimental or investigational.
• Coordinates and seeks opinions with appropriate subspecialty clinicians within WPMG or other KP Regions, or preferred partners.

Service Excellence      

• Documents the review process and decisions for determination of coverage thoroughly, and submits the outcome, including a summary of rationale that can be used in the letter sent to the patient and providers to the review staff within predefined timelines.
• Manages standard and expedited patient appeals within regulatory timelines, providing and seeking additional specialty expertise as indicated.
• Supports the timely review of non-urgent pre-service requests for coverage, post-service reviews, provider reconsideration requests and prepayment clinical review of claims within the regulatory time frame.
• Conducts specialty clinical reviews on potential coverage denials based on the application of clinical review criteria and meets the regulatory standards for review timelines.
• Provides education, consultation and feedback to other medical directors, review staff and care management related to clinical review criteria and outcomes, in the appropriate specialty field.
• Builds KPWA reputation and brand for medical excellence through regular contracted network peer conversations and relationship development.

JOB SPECIFICATIONS

REQUIRED

DESCRIPTION

PREFERRED

Medical Degree

MD with experience in a health care business leadership role not including required experience below

Completion of an accredited fellowship in required specialty

Completion of approved residency program

Documentation of additional training in health plan review, utilization management and quality programs

Certificate of Medical Management

MBA, MHA, MPH – health administration or related field

REQUIRED

DESCRIPTION

PREFERRED

3 or more years

Three to four years of clinical practice experience, in required specialty

Four to six years’ experience in clinical practice with two to four years of experience in required specialty

Additional experience in utilization/quality management would be preferred but is not required

REQUIRED

DESCRIPTION

PREFERRED

MD, DO

Board Certified by ABMS or member of ACPE

Current unrestricted appropriate Washington State license, e.g., physician, Physician’s Assistant, Doctor of Optometry license

Credentialed by KPWA

Washington Permanente Medical Group Shareholder in Good Standing

Board Certified by “program specific accreditation” or another appropriate accreditation

Meets WPMG performance standards for quality, service, access, coding, and documentation

Maintains Board Certification and seeks to maintain knowledge of major advances in the practice of medicine and within specialty area

COMPETENCIES

DESCRIPTION

REQUIRED/PREFERRED

Management

Demonstrated leadership skills with the ability to direct the activities of others on a direct or matrix team basis. 

Ability to collaborate and be influential across structures and roles.

Ability to juggle and effectively and timely addresses the demands of the complex medical environment such as medical/legal issues, staff concerns, customer demands, performance improvement, workforce engagement, etc.

Celebrate successes, recognize excellence in performance, and communicate accomplishments to build pride.

Develops cultural competency and agility in self and others in order to Understand and respond to the different care experiences faced by our diverse patient population.

Translate and communicate Kaiser Permanente mission, vision and performance to staff.

Takes a leadership role to “walk the talk” and models goal-oriented, collaborative high performance.

Understands the fundamentals of bias and is able to take this into account as a leader.

Understands the value of diverse teams and demonstrates commitment to diversifying the medical group and leadership.

Leads by example in the areas of communication, strategic planning, workforce engagement, partnering, and goal setting.

Model and promote an effective partnership within KPWA.

Required

Delivery Systems

Knowledge of delivery system operations, healthcare delivery systems and trends.

Required

Business Acumen

Knowledge of business process and rapid cycle improvement and systems thinking.

Ability to participate in activities to maintain knowledge of major advances in the practice of medicine through attendance of external conferences, educational seminars and involvement in professional association activities.

Ability to participate in activities to enhance knowledge of administrative operations through educational efforts and involvement in professional association activities.

Required

Decision Making

Communication

Ability to challenge established ways and lead change. 

Demonstrated effective problem solving and decision-making skills. 

Proven negotiation and conflict resolution skills.  Excellent communication skills.

Provides clear written and oral communications to support WPMG’s and KP’s vision, mission, and operating plan, as needed or required.

Encourages front line staff to improve care where they work.

Required

Human Resource Skills

Financial and human resource management skills; demonstrated success working with medical staff.

Required