Description

Careers With Purpose

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 53,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.

Job Summary

Reviews physician inquiries for pharmacy, physician-administered, or home infusion pre-authorization and medical necessity requests based on established pharmacy guidelines and contract criteria. Handles calls and correspondence from providers; responds to inquiries, complaints, and reconsiderations. Documents calls in specific software. Using established protocols ensures resolutions provided are presented in a clear and accurate manner. Receives escalated calls that cannot be clinically resolved by first level intervention. Researches, resolves, and responds to provider clinical inquiries. Supports Fraud and Abuse program system oversight. Communicates any suspected fraud discovered by the contact center staff. Recommends course of action for providers where patterns appear outside of guidelines and generally accepted pharmacy standards. Serves as a contact for all internal pharmacy related issues. Functions as a clinical liaison between internal staff and pharmacy network participants. Conducts research necessary to maintain Prior Authorization Criteria, including therapeutic category and comparative drug review. Works with appropriate individuals/vendors to facilitate compliance. Collaborates with quality assurance team to ensure that pharmacy remains in compliance with accreditation standards. Oversees delegation of Pharmacy Benefit Management agreement. Responds to and drafts correspondence to physicians regarding requests on Drug Formulary. Responds to telephone inquiries from physicians, other healthcare professionals, and members regarding select drug information. Keep abreast of industry trends and regulatory changes in the pharmacy industry and evaluates their effect on pharmacy contracts and services. Makes recommendations on program improvements, based on findings and utilization. Participates in various Pharmacy-related projects. Performs appropriate research, analysis, and generates findings report. Submits recommendation to executive leaders for review and input. May assist in implementation and/or coordination of project changes. Performs medication therapy reviews to identify medication related problems, performs interactive consultations and makes recommendations/interventions for members and providers, appropriately documents all pharmacotherapy interventions, responds to questions and provides clarification for requests generated in regards to designated programs.

Requirements

Qualifications

Graduation with a degree suitable for licensure as a pharmacist.

Experience in managed care setting preferred.

Must have current license to practice pharmacy in the State of South Dakota. Pharmacist license in the State of North Dakota required within four months of date of hire into position. Pharmacist license in the State of Minnesota required within eight months of date of hire into position.