DescriptionSHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.
*Selected locations preferred. Candidate must be willing transfer back to working out of Ingenio hub office once notified.
- Researches and synthesizes detailed clinical data related to pharmaceuticals.
- 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 Anthem or health plan medical directors as needed.
- Serves as a clinical resource to other pharmacists on areas such as prospective and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions.
- Prepares information for network physicians.
- Primary duties may include, but not limited to:
- Experience in Injectable/Specialty Drug oversight including Drug Utilization Management.
- Make prior authorization determinations based upon evidence-based clinical data.
- Prior authorization determinations, research, and synthesize detailed clinical data related to injectable pharmaceuticals.
- This position will coordinate with the Medical Directors and RNs in the UM Department, Providers.
- Provides evaluation of member Rx needs and therapies through review of medication history to determine if medications are appropriate.
- Provide injectable drug medical necessity reviews covered under the Medical benefit (Part B).
- Determines potential barriers to compliance and identifies solutions to overcome barriers.
- Adhere to all Medicare and policy and procedures.
- Ensures that providers understand appropriate use of current prescriptions.
- Reviews medication requests with physicians and/or physician representatives when therapies do not meet national standards.
- Serves as a resource to the clinical team in disease management and other clinical areas.
- Must be a registered pharmacist; minimum 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
- 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.
- Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
- Experience with direct patient counseling, provider interaction and/or education preferred.
- Understanding of the Specialty Drug market preferred.
- Clinical knowledge of Biotech/Oncology drugs preferred.
- Part B experience strongly preferred.
- Must have excellent PC skills (Word, Outlook, Excel).
- Clinical pharmacy experience strongly preferred.
- This position is for 2nd shift coverage Monday through Friday 1pm to 10pm with weekend and holiday rotation.
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.
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.
Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.