Pharmacy UM/QA Leader

Job Title: Pharmacy UM/QA Leader

Location: Remote, CST or EST required

**Must hold NY or CT Pharmacy License**

Summary of Job:

This role involves overseeing pharmacy and medical drug Utilization Management (UM) delegates, including those from ESI, CCUM, and NCH. The key responsibilities include ensuring quality assurance by reviewing no fewer than 10 cases per day for each delegate, with a minimum of 30 overturned G&A cases per week. The position requires identifying and addressing inappropriate determinations with delegates, investigating root causes, and implementing corrective measures.

The role involves collaborating with the Pharmacy Operations team to resolve operational challenges and working with the formulary team on proper criteria implementation. It also includes developing clinical QA methodologies, monitoring KPIs in collaboration with the Analytics & Audit team, and reviewing appeals before submission to IRO.

Additionally, the role requires leading and enforcing quality standards for UM functions, creating clinical decision trees, and working with Medical Directors to ensure accurate clinical decisions. The position includes management reporting on productivity, quality, and compliance with pharmacy regulations, as well as providing weekend coverage for emergencies.

Responsibilities:

• Provide active oversight of pharmacy and medical drug UM delegates; ESI, CCUM and/or NCH. The quality assurance process must include no fewer than 10 cases per day for the assigned delegate and a minimum of 30 overturned G&A cases per week.
• Identify cases with inappropriate determinations, open tickets with delegate and address timely with delegate identifying root cause, preventative measure, member and provider impact and correction.
• Collaborate with Pharmacy Operations team to resolve operational and/or technical challenges.
• Work closely with the formulary team to ensure appropriate criteria implementation and branching logic.
• Establish a clinical QA methodology.
• Work closely with the Analytics & Audit team on primary KPIs. Investigate issues associated with KPI results.
• Clinical review of company appeals prior to submission to IRO, effectuate authorization as appropriate.
• Direct the management reporting on productivity, clinical quality, compliance with state and federal pharmacy requirements and timelines.
• Lead, develop and enforce standards of quality, quality assurance, and monitoring for the utilization management function with the assigned delegate.
• Work with practitioners to make clinical decision trees, which will enhance the efficiency of the team.
• Collaborate with the Medical Directors and G&A team ensuring appropriate clinical decisions are made.
• Other duties/projects as assigned.
• Weekend coverage for emergencies.

Qualifications:

• Doctor of Pharmacy degree or Masters in Pharmacy from an accredited school of pharmacy
• Registered Pharmacist: New York State and/or CT pharmacy license or eligible to obtain New York State license/CT state license
• Board certification (Pharmacotherapy, Ambulatory Care, Geriatrics, Internal Medicine, Pediatrics) preferred (Preferred)
• 10+ years of relevant business experience (Required)
• A minimum of 2 years of staff and/or process management experience (Preferred)
• A minimum of 5 years of pharmacist experience (Required)
• Utilization Management experience (Required)
• Residency or 5 years' clinical experience (Preferred)
• Knowledge of pharmaceuticals and disease states to provide advice and consultation to providers and members, and recommend changes to the formulary (Required)
• Possess research and analytical skills sufficient to provide problem resolution and consultation to providers (Required)
• Excellent verbal and written communication skills sufficient to prepare own correspondence and interact with members and providers in provision of advice and guidelines (Required)

The pay for this role is $65 - $75 an hour DOE.

Benefits through CGC: Payday Fridays, Dental, Vision, STD and/or LTD, Voluntary Life & AD&D, Accident, Critical Illness, Hospital Indemnity, Health Advocate EAP, and Health Equity Commuter Benefits, ZayZoon, and 401k.

We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws