Physician Pharmacy Reviewer

This position is critical to Priority Health's mission of improving the health and lives of the people we serve in collaboration with the health plan's provider partners and major delivery systems. Expectations will include appropriate application of utilization management skills and strategies to assure the right care at the right time and the right price in the right location to promote high quality health outcomes. Work entails medical necessity reviews on weekends and holidays. Ideal candidates must have a strong sense of mission, are interested in a high level of collaboration, patient-centered care and evidence-based medicine. The Physician Reviewer can expect to work approximately 2-4 hours on 1- day holidays, 4 – 6 hours per 2 - day weekend, and 6 – 8 hours per 3 - day weekend.

Essential Functions

• Understand Priority Health’s mission, strategic goals, and value proposition for our communities and the people we serve.

• Promote and advocate for patient-centered care, evidence-based medicine, and lower per-capita costs; participate in the development of clinical utilization guidelines, health management programs and clinical quality programs.

• Provide clinical oversight to utilization management.

Qualifications

Required

• Bachelor's Degree

• 3 years of relevant experience in clinical setting

• 3 years of relevant experience Managed care experience

• LIC-Physician (MD) - STATE_MI State of Michigan or LIC-Osteopathic Physician (DO) - STATE_MI State of Michigan

Preferred

• Proven experience and evidence of success in effective physician communication and education skills

• Evaluation of evidence-based standards of care including the ability to critically analyze data

• Clinical program development and assessment

• Physician and clinical practice partnership development and application of utilization management skills and strategies.

• 3 years relevant managed care is required vs. preferred.

• Knowledge of pharmaceuticals and general knowledge on related clinical guidelines

• Knowledge and experience working with CMS rules and regulations related to coverage reviews and appeals – Part D and Part B experience preferred

• Geriatric experience (preferred, but not limiter)

• Ability to work within various systems and use technology efficiently (PA Logic UM portal)

About Corewell Health

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.