Prior Authorization Pharmacist - Temporary

Let’s do great things, together!

About Moda
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.

Position Summary
We are currently seeking a skilled and dedicated pharmacist to join our clinical pharmacy team. In this role, you will have the exciting opportunity to focus on the vital prior authorization functions of our work. Your primary responsibilities will involve making coverage determinations and completing appeal requests, using your clinical expertise to provide coverage decisions based on established criteria, guidelines, and specific plan design. You will be part of a dynamic environment where you can make a significant impact on patient care and contribute to the overall success of our healthcare organization. This is a temporary role that is a WFH.

Pay Range

$103,893.01 - $132,461.48 annually (depending on experience)
*This role may be classified as hourly (non-exempt) depending on the applicant's location. Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Please fill out an application on our company page, linked below, to be considered for this position.

https://j.brt.mv/jb.do?reqGK=27786854&refresh=true

Benefits:

Medical, Dental, Vision & Pharmacy

PTO and Company Paid Holidays

401k - Matching

Required Skills, Experience & Education:

Current active and unrestricted Oregon Registered Pharmacist license, or eligible for Oregon licensure which is to be obtained within 60 days of hire date

Effective communication and interpersonal skills to interact with healthcare providers, internal teams, and external stakeholders

Commitment to service, organizational values, and professionalism through appropriate conduct and demeanor always

Works well under pressure with frequent interruptions and shifting priorities

Follow the company HR policies, Code of Conduct, and all department policies and procedures including protecting confidential company, employee, and customer information

Preferred Skills

Doctor of Pharmacy degree (Pharm.D.)

Experience in clinical therapeutics for specialty drugs

Two to three years of managed care experience

Primary Functions:

Evaluate medication requests for coverage (e.g., prior authorization reviews, non-formulary requests, step therapy exceptions), conducting thorough clinical reviews and assessing their compliance with established clinical guidelines, formularies, and policies

Provide prior authorization pharmacist coverage for rotating weekends and holidays

Provide ad hoc or on call support for urgent medication requests and provide internal pharmacist support to the pharmacy team, appeals unit, and customer services department

Perform coverage determination reviews for all lines of business (i.e., commercial, exchange, government) for pharmacy and medical (physician-administered or home infusion) medications

Participate in the appeals and grievances process by providing clinical expertise and reviewing medication-related appeals and complaints

Complete medical literature evaluation using primary, secondary, and tertiary drug resources to support coverage decision-making and recommendations

Perform peer-to-peer reviews with providers when requested

Make recommendations on medication edit improvements (e.g., programming) and coverage criteria, based on utilization and findings during coverage determination reviews

Provide clear, comprehensive, and timely responses to requests for drug information to members, clients, providers, and internal staff via detailed and thorough documentation within coverage determinations, appeal documentation, and email inquiries

Organize workload, set priorities, complete assignments in a timely manner and utilize resources appropriately while complying with department program standards

Participate in and support department quality assurance and ongoing improvement practices

Remain current on all communications and updated processes relayed through multiple team communication channels and apply to daily duties and responsibilities

Support staff training and development as required

Review, update, and maintain applicable policies and procedures related to clinical pharmacy services

Performs all other related duties as assigned by departmental managers

Working Conditions

Office environment with extensive close PC and keyboard use, constant sitting, and frequent phone communication. Must be able to navigate multiple computer screens. A reliable, high-speed, hard-wired internet connection required to support remote or hybrid work. Must be comfortable being on camera for virtual training and meetings. Work in excess of standard workweek, including evenings and occasional weekends, to meet business need. 

Together, we can be more. We can be better.
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Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. 

For more information regarding accommodations, please direct your questions to Kristy Nehler & Danielle Baker via our humanresources@modahealth.com email.