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Job TitleUtilization Management Specialist Pharmacy - Specialty Pharmacy

                        

LocationBeachwood

                    

FacilityCC Administrative Campus

                     

DepartmentAmbulatory Pharmacy-Medical Operations

                      

Job CodeT98481

                     

ShiftVariable

                       

Schedule8:00am-4:30pm

                       

Job SummaryThe Utilization Management Specialist, Pharmacy provides a high level of patient care and counseling to patients enrolled in the Specialty Pharmacy Patient Management Program. This individual performs activities which includes prior authorization for medication coverage including appeals, follow up assessments for adherence and side-effect management, injection training, and other duties as deemed appropriate. May design and initiate special projects as supervised by the Manager.

                         

Job Details

Job Responsibilities:

Provides prior authorization support for Specialty medications specific to disease state as assigned.Prioritizes and organizes work to meet changing priorities.Utilizes analytical ability required to gather data. Uses clinical judgment to apply predetermined criteria or uses independent clinical judgment when no predetermined criteria exists to identify problems and facilitate resolution.Uses independent clinical judgment in reviewing records to determine appropriate off label use of specialty medication, if proper procedures have been followed, appropriate escalation of PA denials through the appeals process.Makes recommendations regarding appropriateness of the treatment plan specific to the nurse’s assigned disease state.Contacts Physician’s office regarding questions, concerns or problems with the prescription before providing authorization support to other groups so that errors or discrepancies are corrected early in the workflow, making the process more efficient for other groups.Completes prior authorizations for assigned patients with a minimum as deemed appropriate by Manager.Applies clinical studies or guidelines accurately to monitor appropriateness of medications specific to each disease state.Follows department guidelines on escalation processes and refer cases appropriately to pharmacists, teams and manager.Maintains professional work standards including confidentiality, ethical principles, and professional work habits.Maintains and supports collaborative relationships with Physicians and the multidisciplinary team.Documents appropriately in Epic Specialty Encounter notes to provide evidence that the Prior Authorization process for the case was followed.Attends all staff meeting when scheduled to work.Other duties as assigned

Education:

Graduate of an accredited school of nursing with licensure as a Registered Nurse (RN) in the State of Ohio.Bachelor of Science in Nursing preferred.

Certifications:

Current valid license in the State of Ohio as a Registered Nurse (RN).

Competencies (Complexity of Work):

Requires critical thinking skills, decisive judgment and the ability to work with minimal supervisionMust be able to work in a stressful environment and take appropriate action

Work Experience:

Requires three years equivalent full-time clinical experience as a Registered Nurse.Prior Utilization Management experience is preferred.Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes.Analytical ability required to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution.Proficient with Epic.Awareness of licensing and accreditation standards.Proficient with Microsoft Office.Knowledge of prescription benefit and prior authorization requirements for specialty medications, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings; capable of providing in-service education to health care providers on this topic.Must possess advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.

Physical Requirements:

Requires walking, sitting, and/or standing for long periods of time.Requires constant attention to detail, reading of medical records, and meeting deadlines.Works in an environment where there is some discomfort due to dust, noise, temperature.

Personal Protective Equipment:

Follows standard precautions using personal protective equipment as required

                       

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. All offers of employment are follwed by testing for controlled substances and nicotine. All new caregivers must clear a nicotine test within their 90-day new hire period. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after one year.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

Please review the Equal Employment Opportunity poster. 

                  

Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities