WVU Medicine

Role Description To ensure accurate and appropriate gathering of information into the coding classification systems to meet departmental, hospital and outside agency requirements. This includes ensuring appropriate reimbursement, compliance and charging with the various coding guidelines and regulatory agencies. Responsible for obtaining accurate and complete documentation in the medical record for accurate coding assignment. Responsible for the coding of moderately complex patient classes i.e. ED, observations, same day care, etc. Qualifications - High School Diploma or Equivalent. - Current HIM or Coding Certification through one of the following: - American Health Information Management Association (AHIMA) - American Academy of Professional Coders (AAPC) - Two (2) years of hospital coding experience. Requirements - Graduate of Health Information Technology (HIT) or equivalent program OR Medical Coding Certification Program. - Reviews and accurately interprets medical record documentation from all hospital accounts to identify all diagnosis and procedures that affect the current outpatient encounter and assigns the appropriate ICD-10, CPT, or modifier codes for each diagnosis and procedure that is identified. - Assigns hospital codes to a variety of patient classes (i.e. ED, OBS, SDC, etc.). - Assures that quality and timely coding, charging and abstraction of accounts are completed daily for assigned specialty areas. - Maintains and enhances current levels of coding knowledge through quality review, attendance and participation at clinical in-services and coding seminars, internal meetings, study of circulating reference materials, and inclusion of updates to coding manuals. - Assures the accuracy, quality, and timely review of data needed to obtain a clean bill. - Contacts physicians or any persons necessary to obtain information required for accurate code assignments. Works and communicates with other offices in any manner necessary to facilitate the billing process. Company Description United States of America (Non-Exempt) - Company: SYSTEM West Virginia University Health System - Cost Center: 548 SYSTEM HIM Coding Analysis

Role Description Come join Peak Health – a fast-growing provider led health plan, as a Business Intelligence Engineer (Operational Analytics). Your data management and analysis skills combined with your critical thinking will help us advance operational performance across Peak Health by transforming raw data into actionable intelligence that improves efficiency, throughput, quality, and member/provider experience. The Business Intelligence Engineer will collaborate closely with the Operational Analytics team, as well as peers and colleagues, across product, operations, medical management, and provider contracting to support and implement high-quality, data-driven decisions. The ideal candidate has a knack for seeing solutions in data sets and the business mindset to convert insights into strategic opportunities. They will ensure data accuracy and consistent reporting by designing and creating optimal processes and procedures for analytics employees to follow. They will use advanced data modeling, predictive modeling, and analytical techniques to interpret key findings from company data and leverage these insights that will help us design, build, and manage our health plan. Qualifications - Bachelor’s Degree in Business Administration, Mathematics, Computer Science, Statistics, Information Systems, or a related field. - Two (2) years of experience monitoring, managing, manipulating, and drawing insights from data in a managed care company. - Two (2) years of experience working with claims data to evaluate reimbursement changes, payment discrepancies, medical expense opportunities, quality outcomes and risk. - Two (2) years of experience working with Medicare and/or Medicaid Data (preferred). - Epic Accreditation for Cogito, Caboodle Data Model, and Clarity Data Model or able to obtain within 60 days of hire (preferred). - Familiarity with health plan operations, data architecture, and Medicare/Medicaid regulatory environments (preferred). Requirements - Assists with the development, scaling, improvement, and maintenance of data models, dashboards, and analytical solutions supporting Peak Health operations. - Leverages complex analytical tools to provide business and technical expertise to create data driven solutions. - Partners with product, operations, medical management, and provider contracting teams to understand & anticipate reporting requirements, priorities, and key performance indicators. - Supports key business stakeholders, translating data into actionable insights using appropriate analytical solutions. - Produces repeatable and ad-hoc reports for key business stakeholders to measure and interpret business trends. - Participates in a variety of assigned operations initiatives to ensure success in meeting business goals and objectives. - Collects report requirements – interviews and researches business stakeholder needs; drafts, edits and validates requirement documentation. - Provides input on project plans, scope of work, status, and project summary reports. - Communicates results of analysis effectively and regularly to business stakeholders. - Other duties as assigned. Benefits - Scheduled Weekly Hours: 40 - Shift: Exempt/Non-Exempt - United States of America (Exempt) Physical Requirements - Working at a computer. Working Environment - Work will primarily be completed in a remote setting. Occasional travel to office may be required. Skills and Abilities - Strong programming skills with query languages such as SQL and the ability to perform effective querying from multiple tables and databases. - Experience with querying tools such as Microsoft SQL Server Management Studio. - Experience with data visualization tools such as Tableau or PowerBI. - Experience working with Oracle, Teradata, Hadoop, etc. - Strong problem solving and quantitative abilities. - Excellent communication and collaboration skills. - Attention to detail. - Effective time management and organizational skills. - Work independently as well as in a team environment. - Proficient computer skills, including experience with Microsoft Office Suite such as Excel functionality (pivot tables, vlookups, macros, etc.).

Role Description Assists in most aspects of drug distribution that do not require the professional judgment of a pharmacist. An Operations Pharmacy Technician II can only perform some aspects of drug distribution and preparation including assisting training of Operations Pharmacy Technician I. Technicians function in accordance with standard, written procedures and guidelines under the supervision of a pharmacist. Qualifications - High school diploma or Equivalent. - Must possess current licensure as required by state board where services will be provided: - MD: Pharmacy Technician Student Permit or Pharmacy Technician License through Maryland Board of Pharmacy - OH: Pharmacy Technician Trainee License or Certified or Registered Pharmacy Technician License through Ohio Board of Pharmacy - PA: Pharmacy Technician Trainee or Pharmacy Technician License through the Pennsylvania Board of Pharmacy - WV: Pharmacy Technician Trainee or Pharmacy Technician License through West Virginia Board of Pharmacy - Remote Workers Only: Must additionally hold Pharmacy Technician Trainee License or Pharmacy Technician License issued by state of residence. - Nationally Certified Pharmacy Technician through Pharmacy Technician Certification Board (PTCB) or National Healthcareer Association (NHA) OR if applicant has two (2) or more years of pharmacy specific experience, must be obtained within 15 months of hire. Requirements - Associates degree OR Post high school education in a science field of study OR graduate of a pharmacy technician training program. - Nationally Certified Pharmacy Technician through Pharmacy Technician Certification Board (PTCB) or National Healthcareer Association (NHA) upon hire. Core Duties and Responsibilities - Responsible for preparing unit-dose medications, delivering medications, and ordering and delivering drug supplies. - Reads physician orders/prescriptions and prepares medication for dispensing, including unique dosage forms for pediatric and geriatric patient populations. - Has an understanding of standard pharmaceutical/medical terms, abbreviations and symbols commonly used in the prescribing and dispensing of medications. - Communicates with Patients or care givers to determine medication, medication possession, and scheduling delivery, pick up, or shipment of medication. - Accurately prepares and/or delivers controlled substances and maintains all necessary records. - Takes inventory and analyzes patient-care area medication supplies, replacing outdated or deteriorated medications; replaces depleted inventory. - Accurately prepares non-intravenous medications, including oral solutions/suspensions for pediatric patients. - Labels parenteral/Prescription products appropriately. - Performs arithmetic calculations for usual dosage determinations required in medication and solution preparation. - Performs in accordance with departmental standards established for speed and accuracy. - Prepares and labels prepackaged medications after determining usage patterns and prepackaging requirements. Also maintains records related to this. - Maintains inventory and supplies in assigned pharmacy service areas. - Answers telephone and channels calls to appropriate individual. - Ensures that the pharmacy service areas and drug storage areas in the institution are kept clean and orderly. - Assists in the training of pharmacy technicians. - Certain duties cannot be assigned to Pharmacy Technicians because these duties can only be performed by Pharmacists. These restrictions are regulated at state and federal levels and must be followed closely according to state board of pharmacy regulations where the Pharmacy Technician practices. Physical Requirements - While performing the duties of this position, the employee is required to walk and stand or sit for long periods of time. - Must be able to lift 30 pounds and must be able to push 50 pounds. - Dexterity required to finger, handle, and reach. Working Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Company Description West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

Role Description To ensure accurate and appropriate gathering of information into the coding classification systems to meet departmental, hospital and outside agency requirements. This includes ensuring appropriate reimbursement, compliance and charging with the various coding guidelines and regulatory agencies. Responsible for obtaining accurate and complete documentation in the medical record for accurate coding assignment. Responsible for the coding of moderately complex patient classes i.e. ED, observations, same day care, etc. Qualifications - High School Diploma or Equivalent. - Current HIM or Coding Certification through one of the following: - American Health Information Management Association (AHIMA) - American Academy of Professional Coders (AAPC) - Two (2) years of hospital coding experience. Requirements - Graduate of Health Information Technology (HIT) or equivalent program OR Medical Coding Certification Program. - Reviews and accurately interprets medical record documentation from all hospital accounts to identify all diagnosis and procedures that affect the current outpatient encounter and assigns the appropriate ICD-10, CPT, or modifier codes for each diagnosis and procedure that is identified. - Assigns hospital codes to a variety of patient classes (i.e. ED, OBS, SDC, etc.). - Assures that quality and timely coding, charging and abstraction of accounts are completed daily for assigned specialty areas. - Maintains and enhances current levels of coding knowledge through quality review, attendance and participation at clinical in-services and coding seminars, internal meetings, study of circulating reference materials, and inclusion of updates to coding manuals. - Assures the accuracy, quality, and timely review of data needed to obtain a clean bill. - Contacts physicians or any persons necessary to obtain information required for accurate code assignments. Works and communicates with other offices in any manner necessary to facilitate the billing process. Company Description Company: SYSTEM West Virginia University Health System Cost Center: 548 SYSTEM HIM Coding Analysis Physical Requirements - Must be able to sit for long periods of time. - Must have visual and hearing acuity within the normal range. - Must have manual dexterity needed to operate computer and office equipment. Working Environment - Standard office environment. - Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material. - May require travel. Skills and Abilities - Must be able to concentrate and maintain accuracy during constant interruptions. - Must possess independent decision-making ability. - Must possess the ability to prioritize job duties. - Must be able to handle high stress situations. - Must be able to adapt to changes in the workplace. - Must be able to organize and complete assigned tasks. - Must possess excellent written and verbal communication skills. - Must possess the knowledge of anatomy, physiology and medical terminology.

Role Description To ensure accurate and appropriate gathering of information into the coding classification systems to meet departmental, hospital and outside agency requirements. This includes ensuring appropriate reimbursement, compliance and charging with the various coding guidelines and regulatory agencies. Responsible for obtaining accurate and complete documentation in the medical record for accurate coding assignment. Responsible for the coding of moderately complex patient classes i.e. ED, observations, same day care, etc. Qualifications - High School Diploma or Equivalent. - Current HIM or Coding Certification through ONE of the following: - American Health Information Management Association (AHIMA) - American Academy of Professional Coders (AAPC) - Two (2) years of hospital coding experience. Preferred Qualifications - Graduate of Health Information Technology (HIT) or equivalent program OR Medical Coding Certification Program. Requirements - Reviews and accurately interprets medical record documentation from all hospital accounts to identify all diagnosis and procedures that affect the current outpatient encounter and assigns the appropriate ICD-10, CPT, or modifier codes for each diagnosis and procedure that is identified. - Assigns hospital codes to a variety of patient classes (i.e. ED, OBS, SDC, etc.). - Assures that quality and timely coding, charging and abstraction of accounts are completed daily for assigned specialty areas. - Maintains and enhances current levels of coding knowledge through quality review, attendance and participation at clinical in-services and coding seminars, internal meetings, study of circulating reference materials, and inclusion of updates to coding manuals. - Assures the accuracy, quality, and timely review of data needed to obtain a clean bill. - Contacts physicians or any persons necessary to obtain information required for accurate code assignments. - Works and communicates with other offices in any manner necessary to facilitate the billing process. Physical Requirements - Must be able to sit for long periods of time. - Must have visual and hearing acuity within the normal range. - Must have manual dexterity needed to operate computer and office equipment. Working Environment - Standard office environment. - Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material. - May require travel. Skills and Abilities - Must be able to concentrate and maintain accuracy during constant interruptions. - Must possess independent decision-making ability. - Must possess the ability to prioritize job duties. - Must be able to handle high stress situations. - Must be able to adapt to changes in the workplace. - Must be able to organize and complete assigned tasks. - Must possess excellent written and verbal communication skills. - Must possess knowledge of anatomy, physiology and medical terminology. Scheduled Weekly Hours 40 Shift Exempt/Non-Exempt: United States of America (Non-Exempt) Company Description Company: SYSTEM West Virginia University Health System Cost Center: 548 SYSTEM HIM Coding Analysis

Role Description Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position. The West Virginia University Health System, the state’s largest health system and largest private employer, comprises 18 hospitals throughout the state and bordering states. In addition, it includes five institutes, as well as providing management services for other local hospitals through affiliate agreements. Whether you are caring for our patients at one of the critical access hospitals, community sites, regional or academic medical centers, we are all one WVU Health System. Work Here. Thrive Here. Qualifications - Scheduled Weekly Hours: 0 - Shift: Exempt/Non-Exempt - Location: United States of America (Exempt) - Company: SMG System Medical Group - Cost Center: 7994 SMG Teleradiology Multi Locations Company Description The West Virginia University Health System is the state’s largest health system and largest private employer, comprising 18 hospitals throughout the state and bordering states. - Includes five institutes - Provides management services for other local hospitals through affiliate agreements

Role Description To ensure accurate and appropriate gathering of information into the coding classification systems to meet departmental, hospital and outside agency requirements. This includes ensuring appropriate reimbursement, compliance and charging with the various coding guidelines and regulatory agencies. Responsible for obtaining accurate and complete documentation in the medical record for accurate coding/MS-DRG assignment, severity of illness and risk of mortality for each medical record. Must code inpatients and/or interventional RAD cardiology/radiology 90% of current FTE status. Responsible for the coding of the highly complex patient classes i.e. inpatient, interventional, etc. Qualifications - High School Diploma or Equivalent. - Current HIM or Coding Certification through one of the following: - American Health Information Management Association (AHIMA) - American Academy of Professional Coders (AAPC) - Three (3) years of hospital inpatient coding or interventional radiology (IRAD) hospital coding experience. Requirements - Codes inpatient and/or IRAD 90% of current FTE status. - Reviews and accurately interprets medical record documentation from all hospital accounts to identify all diagnosis and procedures that affect the current inpatient stay or outpatient encounter and assigns the appropriate ICD-10-CM, ICD-10-PCS, CPT, or modifier codes for each diagnosis and procedure that is identified (inpatient and IRAD). - Ensures appropriate MS-DRG assignment based on accurate ICD-10-CM and ICD-10-PCS coding assignment and medical record documentation. - Assigns hospital codes to a variety of patient classes (i.e. I/P, IRAD, etc.). - Assures that quality and timely coding, charging and abstraction of accounts are completed daily for assigned specialty areas. - Maintains and enhances current levels of coding knowledge through quality review, attendance and participation at clinical in-services and coding seminars, internal meetings, study of circulating reference materials, and inclusion of updates to coding manuals. - Assures the accuracy, quality, and timely review of data needed to obtain a clean bill. - Contacts physicians or any persons necessary to obtain information required for accurate code assignments. Works and communicates with other offices in any manner necessary to facilitate the billing process. Benefits - Scheduled Weekly Hours: 40 - Shift: Exempt/Non-Exempt - United States of America (Non-Exempt) Physical Requirements - Must be able to sit for long periods of time. - Must have visual and hearing acuity within the normal range. - Must have manual dexterity needed to operate computer and office equipment. Working Environment - Standard office environment. - Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material. - May require travel. Skills and Abilities - Must be able to concentrate and maintain accuracy during constant interruptions. - Must possess independent decision-making ability. - Must possess the ability to prioritize job duties. - Must be able to handle high stress situations. - Must be able to adapt to changes in the workplace. - Must be able to organize and complete assigned tasks. - Must possess excellent written and verbal communication skills. - Must possess knowledge of anatomy, physiology and medical terminology.

Role Description Responsible for educating and training WVU Healthcare Coding Staff as directed by Coding Managers. Will also oversee or perform the overall auditing and education plans for the Coding staff. This position will perform coding quality audits, provide ongoing feedback and education. This position utilizes various coding classifications; ICD-10-CM, ICD-10-PCS, CPT, and other references and software to ensure accurate coding and MS-DRG, HCC and APR-DRG assignment. Qualifications - Graduate of a Health Information Technology (HIT) or equivalent program AND Five (5) years of coding experience; OR - Graduate of a Medical Coding Certification Program AND Five (5) years of coding experience; OR - High School Diploma or Equivalent AND Eight (8) years of coding experience. - Certification in ONE of the following: - Registered Health Information Administrator (RHIA) - Registered Health Information Technician (RHIT) - Certified Outpatient Coder (COC) - Certified Coding Specialist (CCS) - Certified Professional Coder (CPC) Requirements - Bachelor’s degree in Health Information Management or related field (preferred). - Extensive experience in ICD-10-CM, ICD-10-PCS, CPT, and MS-DRG, HCC and APR-DRG assignment for Positions and multi-specialty coding, E&M coding, procedural/surgical coding. - Knowledge of governmental billing and coding regulations including the “Teaching Physician Guidelines” for Professional Coding Positions (preferred). - Previous supervisory or project management experience (preferred). Core Duties and Responsibilities - Manages activities of designated coding personnel in training for WVU Healthcare and assures the monitoring and reporting of respective employee’s developmental activity. - Manages quality improvement audits and training of designated coding staff. - Acts as expert coding resource to coders, clinical documentation improvement, providers and revenue cycle, specialty groups and meetings. - Acts as Super user for all Coding-related Electronic Medical Record Systems necessary for complete and accurate coding and EMR Data Governance. - Develops and maintains coding related policies, procedures, query development, work queues and training materials in conjunction with management. - Communicates with Coding Staff, Medical Staff, Physician Advisor, Department Chairman, and Department Administrators. - Organizes, facilitates, performs, tracks, trends, and reports on internal quality reviews. - Designs and uses audit tools (i.e ROC) to monitor the accuracy of coding, documentation gaps, and billing performed by Coding Specialists. - Coordinates audits performed by outside agencies, acting as a liaison between agency and HIM personnel. - Coordinates coding/documentation denial reviews and facilitates appeal letter formation. - Communicates regularly with the Coding Leadership on activities, problems, coding and/or documentation issues and pending audits. - Ensures audit (external and internal) recommendations are completed. - Extracts and analyzes from various sources then develops action plan when necessary. - Assists with on-boarding of new Coding Specialists regarding coding/quality related policies, audits and initiatives. - Updates Coding Specialists on compliance and other regulatory changes. - Keeps abreast of coding changes, state and federal regulations and coding resources. - May be responsible for development and design of the curriculum for the WVU Healthcare Coding Certificate Program. Physical Requirements - Must be able to sit for long periods of time. - Must have visual and hearing acuity within the normal range. - Must have manual dexterity needed to operate computer and office equipment. - Must be able to lift, push or pull 10-20 pounds. Working Environment - Standard office environment. - Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material. - May require travel. Skills and Abilities - Excellent written and verbal communication skills. - Knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques. - Ability to mentor, educate and train others. - Ensure quality and productivity standards. - Ability to handle high stress and critical situations in a calm and professional manner. - Ability to concentrate and maintain accuracy during constant interruptions. - Independent decision-making ability. - Ability to prioritize job duties. - Adaptability to changes in the workplace and work assignments. - Organizational and time management skills. - Knowledge of anatomy, physiology and medical terminology. - Analytical and problem-solving skills. - Proficiency in office software programs, including medical record and billing systems. - Ability to analyze complex data and reports. Additional Job Description - Scheduled Weekly Hours: 40 - Shift: Exempt/Non-Exempt: United States of America (Exempt) - Company: SYSTEM West Virginia University Health System - Cost Center: 539 SYSTEM HIM Provider Based Coding Analysis

Role Description Facilitates improvement in the overall quality and completeness of clinical documentation to assure accurate coding assignment, severity of illness and risk of mortality through extensive interaction with, and education of, providers and multidisciplinary team members. May perform at a level requiring continued feedback and monitoring or mentoring. Qualifications - High School Diploma or Equivalent - Three (3) years inpatient acute care coding or CDI experience OR - Three (3) years clinical experience as Registered Nurse in an inpatient acute care setting OR - Three (3) years of clinical experience as Licensed Practical Nurse in an inpatient acute care setting Preferred Qualifications - Experience in Risk Adjusted Coding or Evaluation and Management - Two (2) years of CDI experience Core Duties and Responsibilities - In collaboration with the providers and staff, identifies and records principle diagnoses, secondary diagnoses, procedures, and assigns a working Diagnostic Related Group (DRG). - Conducts initial concurrent review and ongoing re-reviews for all selected admissions by documenting findings regarding DRGs, APR-DRGs and Value Based Purchasing/Quality measures. - Identifies need to clarify documentation through quality audits in records and initiates communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness. - Provides information and ongoing education as necessary to providers and staff on documentation issues, guidelines, and unanswered queries. - Promotes compliance with CMS, Medicare documentation, and coding and billing regulations. - Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Reports results assessment and improvement processes to the appropriate administrative levels. - Collaborates with the Quality Department to ensure documentation meets quality initiative standards used for measuring and reporting hospital and provider outcomes. - Collects, analyzes and submits timely, accurate and complete reports of clinical documentation information used for measuring and reporting Hospital and Provider outcomes data. - Facilitates in the education and training of new associates concerning clinical documentation improvement guidelines and processes. This may include providers, CDIs, coders, and other healthcare providers. - Works with the Coding Specialists on any issues that arise concerning documentation, providers, and queries to enhance the concurrent process to enable prompt coding. - May provide educational support in terms of clinical/coding or process at manager’s discretion and as need arises. Physical Requirements - Must be able to sit for long periods of time. - Must have visual and hearing acuity within the normal range. - Must have manual dexterity needed to operate computer and office equipment. Working Environment - Standard office environment. - May be exposed to standard patient care environment. - Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material. - May require travel. Skills and Abilities - Must possess excellent written and verbal communication skills, as well as interpersonal skills necessary to communicate effectively. - Must possess the knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques required. - Must possess the ability to accept mentoring, education and training from others. - Must meet quality and productivity standards. - Must be able to concentrate and maintain accuracy during constant interruptions. - Must possess the ability to prioritize job duties. - Must be able to adapt to changes in the workplace and work assignments. - Must possess organizational and time management skills. - Must possess the knowledge of anatomy, physiology and medical terminology. - Must possess analytical and problem solving skills. - Must be proficient in office software programs. - Must be able to work independently with minimal supervision. Additional Job Description - Scheduled Weekly Hours: 40 - Shift: Exempt/Non-Exempt: United States of America (Exempt) - Company: SYSTEM West Virginia University Health System - Cost Center: 538 SYSTEM HIM CDI

Role Description Reporting to the Manager of Clinical Pharmacy, the Clinical Utilization Management Pharmacist is primarily responsible for performing drug utilization review for initial determinations and/or appeals for our ASO clients, Medicare Advantage plan, and any future lines of business as well as collaborating as an integral member of the pharmacy team. The responsibilities of this position also include: - Serving as a subject matter expert for pharmacy utilization management. - Ensuring the timely execution of all drug reviews in compliance with accreditation and regulatory standards. - Working with our Medical Director and Clinical Formulary team to review any specialty medication requiring a specialty consult. - Identifying utilization review trends and areas of improvement that need to be addressed. Qualifications - Must possess current and unrestricted license to practice pharmacy issued by state of residence. - Three (3) years of experience as a pharmacist in a clinical setting. - Two (2) years of managed care experience. - Specific knowledge of CMS regulations, HIPAA and regulatory environment (preferred). Requirements - Make prior authorization and step therapy determinations for drug utilization reviews based upon available clinical evidence and supporting documentation for all lines of business. - Participate in the appeals process for drug reviews for all lines of business. - Own the operational execution of the drug utilization review process. - Serve as an inter-departmental subject matter expert for utilization management as it relates to drug reviews. - Work with the Manager of Clinical Pharmacy to ensure the timely execution of all drug reviews in compliance with accreditation and regulatory standards. - Work with the Manager of Clinical Pharmacy and Medical Directors to identify review trends and policy needs that need to be addressed. - Work with the Manager of Clinical Pharmacy and Director of Clinical and Technical Integration to identify and escalate operational and technical issues as they relate to drug utilization management reviews that need to be addressed. - Assist with internal and operational policy needs as they relate to drug utilization management review. - Work with the Manager of Clinical Pharmacy to resolve questions and disputes from our clients and participating providers regarding drug review determinations. - Work with Medical Directors and formulary team to review and make recommendations on specialty drugs requiring a specialty consult as defined by our organization. - Assist in monthly analysis of claims data to assess effectiveness of current formulary and utilization management strategies. - Serve as a clinical pharmacy preceptor for residents and rotational pharmacy students as needed. - Assist in creation of training materials for utilization management operational processes as needed. - Assist in creation of clinical development tools for education as it relates to utilization review decision making as needed. Benefits - Scheduled Weekly Hours: 40 - Shift: Exempt/Non-Exempt: United States of America (Exempt)