Job Description

About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

• Review and provide clinical decisions/recommendations for provider/member submitted appeals and grievances for medically administered medications as well as pharmacy related medications and items for all lines of business.
• Analyze pharmacy data (appeal approval/denial rates, claims, clinical, formulary, financial, etc.) to assist with UM development.
• Assist with formulary development for all lines of business.
• Provide clinical assistance to pharmacy staff for daily operations.

Responsibilities

Primary Job Responsibility

• Responsible for reviewing and providing clinical decisions/recommendations for provider/member submitted appeals and grievances for medically administered medications as well as pharmacy related medications and items for all lines of business.
• Collaborate with the Appeals & Grievance Department, Medical Directors, and Prior Authorizations vendors.
• Maintain turnaround times for all appeal and grievance reviews.
• Review appeal/grievance requests per plan-specific criteria, MassHealth-developed criteria, National Coverage Determinations, and Local Coverage Determinations, Evidence of Coverage, Member Handbooks.
• Follow regulatory rules and processes for Massachusetts, CMS, Medicaid, state Connector programs.
• Consult with internal and external stakeholders as needed.
• Consult with providers.
• Participate in managing clinical issues resolution; work with medical providers and vendors to coordinate and resolve member issues.
• Provide recommendations, as appropriate, to update current prior authorization criteria due to appeals and grievance data.
• Assist with formulary and criteria development for all lines of business.
• Participate in general drug information support for internal and external clients.
• Provide clinical assistance to pharmacy staff for daily operations.

Qualifications

Qualifications requirements

Education

RPH or Pharm D

License

Current license to practice as pharmacist in Massachusetts without restriction

Experience

• 3 years, preferably with at least 1 year in a managed care environment; 1-2 years professional experience practicing as a clinical pharmacist.
• Recent experience related to member and/or provider appeals and drug coverage determinations is a plus.
• Able to evaluate clinical pharmacy data, coverage criteria and drug monographs.
• Able to understand and use computer databases, EMRs, Excel, Word, PowerPoint and others.
• Able to write and orally communicate clinical decisions to physicians and other healthcare personnel.
• Excellent communication skills, coordination, and planning skills along with an ability to interact with a variety of audiences to build collaboration and consensus.

Pay Range Disclosure:In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $ 135,000-$145,000 annually which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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