Exemption Status:
United States of America (Exempt)
$108,515 - $152,464 - $196,412
“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”
This position is not eligible for Sponsorship.
MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!
Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.
At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!
Job Description
Summary
The Clinical Quality Pharmacist is responsible for performing clinical audits of Prior Authorization (PA) and Appeals staff and Utilization (UM) delegate(s) across all lines of business. This role involves interpreting, drafting, and modifying clinical-related documents and quality reports in alignment with regulatory and accreditation requirements, as well as Client requests.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
• Develops and/or implements clinical audits and reporting for all Client lines of business
• Evaluates the accuracy of case reviews performed by PA and Appeals staff and UM delegates
• Creates, administers, and manages inter-rater reliability (IRR) testing to ensure consistency amongst reviewers aligned with organizational and accreditation quality standards
• Analyzes IRR results to identify trends, gaps, and opportunities for improvement, as well as provides detailed reporting to oversight committees and leadership
• Monitors PA and Appeals processes and systems for improvement opportunities
• Reviews and assesses appropriateness of PA guideline requests, confirming applicability and compliance with established accreditation requirements
• Works closely with internal departments to resolve any non-compliance identified
• Meets with and provides audit reports to PA and Appeals leadership and staff
• Develops ways to reduce issues and improve quality through process or automation
• Responsible for quality assurance of PA and Appeals notifications meeting compliance with accreditation, regulatory, and client requirements
• Prepares reports (i.e. Utilization Management Program Evaluation, quality reporting suite, IRR)
• Develops client-facing communications focused on the organization’s quality assurance, compliance, and continuous improvement efforts
• Maintains department and company policies and procedures relating to quality.
• Supports maintaining MedImpact’s and its Clients’ NCQA and URAC accreditations.
• Supports the targeted audit program, including audits of drug categories, high-risk clinical programs, and other identified clinical risk areas.
• Supports delegation oversight activities, including audits, calibration sessions, reviewer training, and monitoring of corrective actions through closure.
• Other duties as assigned.
Supervisory Responsibilities
No supervisory responsibilities
Client Responsibilities
This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills…