Supervisor Clinical Pharmacy - Moda Health

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 as Supervisor Prior Authorization. In this position you will play a crucial role in ensuring the efficient and accurate processing of prior authorizations and appeals across multiple lines of business and benefits. This role requires a deep understanding of clinical knowledge, pharmacy operations, state and federal regulations, along with demonstrated leadership skills to support a team of pharmacists and collaborate with pharmacy technicians, customer services representatives, appeals coordinators, and prescribers. Your primary responsibilities will involve providing support, training, and quality oversight to prior authorization staff, collaborating with other teams, ongoing problem-solving of clinical and operational issues, process improvement, and management of staffing/scheduling. In addition, in this role you will use your clinical expertise to provide coverage determinations and complete appeals requests based on established criteria, guidelines, and specific plan design. By joining our team, you will be part of a dynamic environment and cooperative team where you can make a significant impact on patient care and contribute to the overall success of our healthcare organization. This is a FT Hybrid role based in Portland, Oregon. 


Pay Range
$128,858.77 - $164,296.49 annually (depending on experience)
*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=27745148&refresh=true


Benefits:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education:

• Doctor of Pharmacy degree (Pharm.D.) preferred, or Bachelors of Pharmacy degree.
• Valid Registered Pharmacist (RPh) license in the State of Oregon, or ability to become licensed within three months of employment.
• Prior supervisory experience preferred.
• Experience working in prior authorization or appeals, or other similar duties.
• Ability to work collaboratively with other departments across the Moda organization.
• Demonstrate a commitment to service, organization values, and professionalism through appropriate conduct and demeanor.
• Effective communication and interpersonal skills to interact with internal teams, healthcare providers, and external stakeholders.
• Ability to maintain confidentiality and project a professional business image.
• Works well under pressure with frequent interruptions and shifting priorities.
• Proficient with Microsoft Office applications and experience with pharmacy workflow platforms.
• Regular attendance, dependability, and promptness required. Ability to attend regular meetings in-person as needed.

 

Primary Functions:

• Manage a team of pharmacists. Provide and/or coordinate proper prior authorization training for new and existing pharmacist staff, as well as provide ongoing coaching and mentoring through constructive feedback, encouraging desirable actions and promoting a positive learning environment.  
• Complete quality evaluations and retrospective reviews of pharmacy team coverage determinations to support various regulatory and compliance audits and to ensure consistency between reviewers and identify opportunities for additional training.
• Act as a clinical leader across the prior authorization unit to ensure clinically appropriate execution of review strategies and uphold established, or develop as needed, processes and procedures.
• Serve as a primary resource and subject-matter expert pertaining to the medication coverage process and address escalated issues while working collaboratively with other pharmacy team leaders and external department leaders.
• Represent clinical pharmacy in a professional and positive manner during hearings, audits, and other regulatory or compliance initiatives.
• Ensure compliance with state legislative requirements, Board of Pharmacy standards, and federal regulations related to pharmacy program management and services, providing oversight, and supporting adherence to these guidelines within the team.
• Attend and/or lead regular team and department meetings to discuss workload, address challenges, and provide updates on workflow changes.
• Collaborate with other pharmacy team leaders and external department leaders to promote efficient and consistent prior authorization and appeal workflow expectations and improvements.
• Oversee and maintain staffing schedules to ensure appropriate coverage, coordinating time-off requests, monitoring workload and adjusting staffing levels as necessary to meet operational demands.
• Update, maintain, and develop workflow guidelines, policies and procedures, and other necessary tools to maximize productivity and standardize practices in the department and/or practice area.
• As needed, perform coverage determinations (i.e., prior authorization reviews) and appeals requests for all lines of business (i.e., commercial, exchange, government), across medical and pharmacy benefits, according to criteria guidelines and in compliance with Medicare, Medicaid, and state regulations.
• Engage in clinical and operational functions in partnership with external vendors and clients to ensure timely responses and resolution of problems or escalated cases.  
• Availability for rotating weekend/holiday pharmacist coverage for medication requests and provide internal pharmacist support to the pharmacy team, appeals unit, and customer services department, as needed.
• Provide recommendations on medication edit improvements (e.g., programming) and coverage criteria, based on utilization and findings during coverage determination reviews.
• Deliver clear, comprehensive, and timely responses to requests for medication information to members, clients, providers, and internal staff via detailed and complete documentation within coverage determinations, appeal documentation, complaints and grievances, and email inquiries.
• Analyze and monitor medication use through assessment of pharmacy claims data or other reporting to develop clinical strategies to drive utilization towards high-value medications.
• 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.
• Performs all other related duties as assigned by departmental managers.

Working Conditions & Contact with Others

• Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business needs.
• Interdepartmental work within the company including Customer Service, Healthcare Services, Legal, Marketing, Medicare/Medicaid, Membership Accounting, Quality Management, Policy, Regulatory & Compliance, and Sales & Account Services. External work outside of the company with Pharmacy Benefit Manager (PBM), medical management organizations, CMS, pharmaceutical manufacturers, consultants/producers, auditors, business partners/vendors, clients, prospective clients, physicians and other prescribing providers, and pharmacists.

 

Together, we can be more. We can be better.
 
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 and Daniel McGinnis via our humanresources@modahealth.com email.