Job Description

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

Evaluates utilization management criteria and impact for operational needs, supports and maintains configuration needs, develops clinical recommendations for the client, research policy drivers, and coordinates with operations, claims, network, reporting, and other internal departments as needed. 

Your role in our mission

• Utilization Management: Providing a thorough review of the clinical and pricing data to support clinical strategies; involves detailed reporting analysis.
• Retro DUR Initiatives: Regularly reviews and monitors prescription claims data and prescribing practices identified as outliers by internal and/or external analysis of pharmacy claims data to develop relevant Retrospective DUR initiatives. Present initiatives to the P&T or DUR Board including methods, interventions, communication, and outcomes. 
• Telephonic Consultations/Interventions: Contacts physicians and prescribers identified as needing consultation to provide coaching on prescribing practices that have been identified as outliers. Reviews prior authorizations and determine opportunities for interventions. 
• Intervention Tracking and Documentation: Tracks contact attempts and contacts per operations procedures. Documents content of and results of consultations as defined in operations procedures; maintains records as required. 
• Operations: Contributes to the success of the operations of the pharmacy program by assisting with the implementation and management of both written and verbal communications to physicians and prescribers and maintenance of the edits and data elements that support the edits. Is available for consultation on pharmacy-related questions and issues for others within the organization (e.g. health coaches, care managers, etc.). Updates and maintains program engine, coding, consultation sheets and outreach program as needed. 
• Quality Improvement: Contributes to program improvements by using continuous quality improvement processes, by being proactive in identifying improvement opportunities and by contributing on-going consultation and collaboration with product leaders. 
• Medical/Clinical: Upholds clinical integrity of pharmaceutical solutions by staying up-to-date on medication information, contributing to the identification of pharmacy program best practices, collaborating with Medical Directors, Medical Dept, and Clinical Dept and provides pharmacy expertise within the organization. 
• Other duties as assigned. Contributes creative solutions to improve operational efficiency and effectiveness of pharmacy team.

What we're looking for

• Minimum of five (5) years of experience in pharmacy benefit management or pharmacy managed care. 
• Detailed knowledge of Medicaid at the state and federal level. 
• Licensed pharmacist. 
• Ability to communicate succinctly and accurately in both written and verbal English in various group settings from individuals to large groups. 
• Ability to manage various projects simultaneously. 
• Experience evaluating healthcare data/outcomes. 
• Demonstrated leadership ability to drive results across the PBM through team influence and collaboration in a matrixed/shared service organizational model. 
• Experience with end-to-end pharmacy claims lifecycle, clinical operations, call center management, medication pricing methodologies, NCPDP standards, financial management and managed care statute. 
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). 
• Proficient PC abilities (strong knowledge in MS Office), work organization, and problem resolution skills. 
• Proficient on multiple virtual communication platforms (Microsoft Teams, Skype, Zoom, etc.). 

What you should expect in this role

100% remote with 10% travel required. 

The pay range for this position is $113,700.00 - $162,400.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.

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