Clinical Pharmacist

At Express Scripts, a Fortune 100 company, we provide pharmacy benefits management services to tens of millions of consumers through thousands of employers, government and union health plans. We call St. Louis home, but there are administrative, pharmacy, and customer service operations throughout the United States and Canada. Express Scripts continues to expand its services with more than 14,000 employees focused on our mission to make the use of prescription drugs safer and more affordable Since 1986, the company';s legacy of independence ensures that our interests are aligned with plan sponsors and their members. We share a common cause with each of our clients to help offer a healthy prescription-drug benefit today and into the future. As an employee you can be proud knowing you';re improving the quality of life of millions of people every day.
ABOUT THE DEPARTMENT
The Client & Patient Services organization is responsible for ensuring high-quality service delivery to Express Scripts'; members and clients in a cost-efficient manner. Patient Services provides mail pharmacy services, addresses members'; inquiries and provides value-added consultation. In addition this organization includes Client Services, which encompasses client and benefit administration, quality control, implementation, client support center (CSC), participant materials, clinical operations and eligibility. In addition, Client & Patient Services includes centralized functions to drive continuous process improvement, pharmacy compliance and forward-looking planning. This organization also includes Medical Affairs, Clinical Services, and Express Scripts'; Pharma Business Services subsidiary.
RESPONSIBILITIES
JOB SUMMARY:
Provide clinical support and oversight for all utilization management (UM) activities. Responsible for finalizing all denials of clinical prior authorization override requests and overseeing the appeals and reconsideration processes. ESSENTIAL FUNCTIONS:
1. Provide clinical support for the Prior Authorization department and for utilization management activities. This includes the responsibility for finalizing all denials of clinical prior authorization override requests for all utilization management programs ( including PA, step therapy, quantity level override limits, non-formulary overrides, benefit exclusion overrides and brand-generic overrides) in accordance with the plan sponsors benefit design. Involves direct communication with physicians and other health care professionals. Participation in on-call rotation for after hours (24 hours a day, 365 days per year) coverage for Utilization Management Prior Authorization Program. 2. Contribute to the development, updating, maintenance and communication of clinical criteria used for Prior Authorization and clinical overrides across the book of business. This includes:
- Membership on the Therapeutic Assessment Committee (TAC) and the Utilization Management Committee (UM). - Generation of all ESI and client specific criteria into lay version criteria (criteria algorithms for the PA representatives to administer) Involvement in direct client interaction to communicate issues related to the Utilization Management Prior Authorization program. 3. Work in conjunction with other departments to assure that new or existing clients are successfully implemented into the PA UM programs. These departments include Account Management, Client Benefit and Administration, PA Research, Drug File, Drug Evaluation Unit, and The Office of Clinical Evaluation and Policy (OCEP). 4. Provide appeals and reconsideration reviews and/or determinations and processes as appropriate for clients across all business divisions. This includes having knowledge of, and ensuring compliance with, and assuring that all State and national federal regulations and accreditation requirements are met (e.g., NCQA, ERISA). 5