PharmD Reviewer, Medicare

Job Summary
Responsible for providing support and clinical review in a variety of areas, that includes reviewing & resolving Medicare Part B (medical) Appeals in accordance with the standards and requirements established by the Centers for Medicare and Medicaid (CMS), as well as work directly with the Quality team on HEDIS measures, performing medication reconciliation/adherence to satisfy specific measures and working directly with providers.

Knowledge/Skills/Abilities

• Responsible for clinical review for Part B Drug Appeals, researching appropriate peer reviewed medical literature as needed and applying appropriate clinical criteria while maintaining confidentiality
• Works directly with the Quality team on HEDIS measures supporting adherence and strategy to meet goals for measures; Completes medication adherence as needed for at-risk members in collaboration with CM, Providers and the Pharmacy department by performing medication adherence calls & provides education to providers on HEDIS measures
• Ensures all cases have been organized, categorized and documented thoroughly and correctly; Prioritizes and organizes tasks to meet compliance deadlines, assuring timeliness and appropriateness of responses in accordance with state, federal and Sonder Health Plans’ policies and procedures.
• Researches issues utilizing systems and clinical knowledge and approved "Decision Support Tools" in the decision-making process
• Collaborates with other clinical staff, Medical Directors and other team members as appropriate as well as works with other non-clinical staff as needed to help understand prescription drug complaints
• Analyzes work processes and identifies areas where procedures and quality could be improved
• Ability to meet established productivity, schedule adherence, and quality standards with reliably to meet work schedules and deadlines.
• Attends meetings as required; completes all necessary trainings
• Performs and assists in other duties and special projects as required
• Requires communicating directly (verbally and in writing) with members and providers to obtain relevant information and inform of decisions and next steps

Required Education

• PharmD

Required Experience

• Medicare Managed Care complaints, appeals and grievances or utilization management experience

• Excellent research skills
• Understanding of computer programs including but not limited to Microsoft Office and other related applications as well as ability to navigate CMS and state websites and systems as applicable
• Ability to work independently and collaboratively with cross-functional teams in a highly matrixed organization

Preferred Education/Experience

• Preferred experience/participation in CMS and State Audits as well as experience with all levels

of the Medicare appeals process (ALJ, QIO, QIC)