Medical Director, Pharmacy Services

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About Capital Rx:

Capital Rx is a next generation pharmacy benefits manager, overseeing prescription benefit plans on behalf of employers, unions, and government entities. Determined to transform an outdated model, Capital Rx’s mission is to change the way prescription benefits are priced and administered in the US, unlocking enduring social change. Through our platform approach, Capital Rx delivers data-driven insights and actionable strategies that reduce costs, while improving patient outcomes. Our commitment to innovation, technology and service is the reason why Capital Rx is among the fastest-growing PBMs in the country.

Position Summary:

The Clinical Pharmacy Services department provides clinical business support to the entire enterprise and provides clinical support for Capital Rx’s clinical prior authorization programs, consultative support to the P&T process, formulary development, drug information services and direct client activities as assigned. This position will report to Senior Vice President of Pharmacy. This position may provide consultative clinical support to Account Management in support of Key Clients as assigned. This position transacts UM activities (prior authorization and appeals) and responds to prescriber inquiries related to UM transactions and more generally related to Capital Rx’s coverage policies. Medical Directors represent the clinical decision making and professional thought process of the prescriber as a stakeholder across the enterprise’s decisions and planning.

Position Responsibilities:

  • Director will spend a portion of most days completing assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals when appropriate
  • Makes clinical determinations in accordance with medical necessity and contract criteria
  • Performs scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to requesting prescribers
  • Support the Department’s responsibilities to provide peer to peer phone call support to physicians/prescribers who call the company with specific and general questions about our clinical programs, communications and utilization review decisions
  • Communicates effectively and confidently with members to promote positive health outcomes
  • Actively participates in the development of utilization management (PA) criteria and clinical policy revisions/reviews
  • Co-chairs the Quality Management Committee and provides oversight for Capital Rx’s Quality Improvement Projects (25% of time) and Mandatory Performance Measures
  • Ability to work in a fast-paced environment with shifting priorities

Qualifications / Profile:

  • Must be graduate of an accredited Medical School and Residency Program
  • ABMS or AOA Board Certified in a recognized medical specialty, preferably in a Primary Care field (Internal medicine, Family Medicine) or a specialty within Internal Medicine such as Cardiology, Rheumatology, or Endocrinology
  • Possess an unrestricted active license to practice medicine in a State, Territory, Commonwealth of the United States, or the District of Columbia
  • Required annual Continuing Medical Education (CME) up to date and must remain current in medical and management areas during employment
  • 3+ years clinical experience in direct patient care
  • Demonstrated experience in clinical outcomes, working knowledge of medical statistics, regulatory agencies, and analytic programs
  • Ability to work with virtual teams of pharmacists to develop clinical programs/guidance for physicians and other prescribers
  • Licensed in Texas or willing to obtain licensure in Texas within agreed upon time frame
  • Management and time management skills to meet competing priorities and organizational goals
  • Knowledge of PBM environment, quality improvement and UM practices in a managed care environment
  • Knowledge of and appreciation for requirements of regulatory and accreditation agencies
  • Able to manage multiple priorities and deadlines
  • Excellent verbal, written, interpersonal and presentation skills
  • Strong knowledge of clinical medicine, health care delivery and the ability to acquire new scientific and medical knowledge
  • Proficiency with Microsoft Office applications. (e.g., MS Word, Excel, and PowerPoint minimum)-PA Hub experience is a plus
  • Understanding of the Project management process and proven experience in staff and budget management is strongly desirable

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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Location

New York, NY

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