Position title
PA Pharmacist Lead

The PA Pharmacist Lead primarily collaborates with Clinical Innovation and Operations team members to review prior authorization (PA) requirements, addressing clinical questions from members, prescriber, pharmacy personnel and Health Plans. He or she will oversee a team of pharmacists and pharmacy technicians for the PA workstream. The PA Pharmacist Lead will serve as a Subject Matter Expert (SME) for PA and clinical decision-making activities.

  • Practices within scope of licensure and maintains active, non-restricted licensure.
  • Monitors day-to-day operations to ensure compliance with timelines and other operational functions.
  • Serves as a primary resource and SME pertaining to the PA and appeals process.
  • Researches and appropriately responds to PA guideline coding and rationale questions.
  • Reviews PA requests and provides concise, applicable, comprehensive and timely responses to requests for drug coverage.
  • Performs coverage determinations and appeals requests according to criteria guidelines and in compliance with all state and federal regulations, including Medicare and Medicaid.
  • 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.
  • Conducts training and mentoring to PA pharmacists and technicians, inter-rater reliability evaluations. Creates and utilizes process documents for the PA team.
  • Conducts root-cause analysis for any issues associated with a PA request.
  • 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 program system oversight and communicates any suspected fraud discovered.
  • Assures compliance to RxAdvance policies and procedures.
  • Stays abreast of new regulations to ensure regulatory compliance of prior authorization guidelines.
  • Follows all state and federal regulations applicable to PBM operations and utilization management.
  • Have a thorough understanding of, and perform in compliance with, the current PBM v2.2 URAC standards applicable to the position.
  • Compliance with NCQA standards applicable to the position and Quality Management.
  • Bachelor of Science degree in Pharmacy required. Pharmacy Doctorate (PharmD) preferred
  • Managed Care or Clinical Residency program residency preferred
  • 5+ years of experience in pharmacy and/or prior authorization management
  • Expert knowledge of pharmaceutical science, managed care and policy development as well as state and federal controlled substances and related laws, rules, and regulations
  • Registered and in good standing with the Board of Registration in Pharmacy (multiple states will be required)
  • Active, non-restricted pharmacist license
  • Applicants must be able to pass a background investigation as all offers are pending a successful completion of background check per the company polic
Job Location
Southborough, MA
Working Hours
Full Time
Date posted
September 2, 2020
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Position: PA Pharmacist Lead

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