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Oncology Pharmacist Clinical - Carelon Insights (AIM)
Job Family: Medical and Clinical
Type: Full time
Date Posted:Mar 06, 2023
Req #: JR57726
National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint
Carelon Insights (AIM )
Oncology Benefit Management
Location Flexible - Work From Home eligible
Responsible for managing the selection and utilization of pharmaceuticals and supports core clinical programs such as DUR, DIS and formulary management.
Primary duties may include, but are not limited to:
Researches and synthesizes detailed clinical data related to pharmaceuticals.
Prepares and presents therapeutic class reviews and drug monograph information to the Pharmacy and Therapeutics Committee.
May review and approve or deny coverage for pharmaceuticals (as permitted by state/federal law or state/federal program contracts) based on medical necessity criteria, and coordinates with Elevance Health or health plan medical directors as needed.
Serves as a clinical resource to other pharmacists on areas such as prospective, inpatient and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions.
Prepares information for network physicians.
Determine medical necessity of requests using applicable clinical criteria, which may include AIM/Carelon Insights Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines, and CMS Coverage Determinations, as applicable.
Perform pharmacist-level case review of oncology pharmacy utilization requests following initial clinical intake on our portal or referral specialists to encourage appropriate, high-quality, cost-effective drug therapy; and to identify opportunities for improvement in efficiency
Conduct consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, dosing, and appropriate sites of service.
Discuss clinically appropriate alternative pharmacologic treatments, dosing schedules and sites of care with ordering providers when consistent with applicable clinical criteria.
Provide education regarding applicable clinical criteria.
Perform first level provider appeals of coverage decisions.
Demonstrate and maintain knowledge of applicable clinical criteria and relevant AIM/Carelon Insights policies pertaining to utilization review.
Continually monitor the quality and efficiency of the Coverage Determination process including coverage criteria, denial language, and communication with prescribers
Responsible for staying current with clinical literature and guidelines, and relaying those to the program development core teams.
Requires BA/BS in Pharmacy.
Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background.
Requires a registered pharmacist.
Must possess an active unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh). PharmD preferred.
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US, unless they are command-sanctioned activities. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
For candidates working in person or remotely in the below locations, the salary* range for this specific position is $109,200 to $196, 560.
Locations: California; Colorado; Nevada; Washington State; Jersey City, NJ; New York City, NY; Ithaca, NY and Westchester County, NY
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact firstname.lastname@example.org for assistance.
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