Specialty Pharmacy Case Reviewer

Description

Kaiser Permanente Washington Permanente Medical Group is seeking a part-time provider (0.1 FTE) to support the Specialty & High-Cost Medication Advanced Review Partnership (SHARP), Peer Review and Medication Safety.

In partnership with specific Kaiser Permanente Washington (KPWA) Pharmacy staff, this individual reviews select, new drug starts and may discuss appropriate treatment options with the members’ specialist in the appropriate specialty, consistent with Kaiser Permanente (KP) recommended clinical pathways. Special projects as assigned.

As needed, ensures that requests for coverage are adjudicated using professionally recognized standards and criteria. Requests are reviewed for clinical indications, appropriateness, and compliance with contract language. This is achieved through well documented case review, the consistent application of decision tools, criteria and data collection, and feedback to regional medical directors, program chiefs, individual physicians and care management related to clinical review outcome trends.

• Able to work well with other health professionals (pharmacists, RNs, case managers) to effectively facilitate appropriate specialty level of care for KPWA patients in a variety of care settings.
• Assists in the development of clinical review criteria and programs in the appropriate specialty.

• Engages in collegial and respectful telephone conversations with physicians and other health care providers who request consultation regarding coverage issues and discuss options for resolution.
• Assists in conversations around advanced therapeutics discussions for therapy.
• Works with the Clinical Guidelines staff, Medical Technology Committee, and Pharmacy and Therapeutics Committee in reviewing requests for new services to determine whether they are medically necessary, effective, or experimental or investigational.
• Coordinates and seeks opinions with appropriate subspecialty clinicians within WPMG or other KP Regions, or preferred partners.
• Documents the review process and decisions for determination of coverage thoroughly, and submits the outcome, including a summary of rationale that can be used in the letter sent to the patient and providers to the review staff within predefined timelines.
• Manages standard and expedited patient appeals within regulatory timelines, providing and seeking additional specialty expertise as indicated.
• Supports the timely review of non-urgent pre-service requests for coverage, post-service reviews, provider reconsideration requests and prepayment clinical review of claims within the regulatory time frame.
• Conducts specialty clinical reviews on potential coverage denials based on the application of clinical review criteria and meets the regulatory standards for review timelines.
• Provides education, consultation and feedback to other medical directors, review staff and care management related to clinical review criteria and outcomes, in the appropriate specialty field.
• Builds KPWA reputation and brand for medical excellence through regular contracted network peer conversations and relationship development.

Medical Degree

MD with experience in a health care business leadership role not including required experience below

Completion of an accredited fellowship in required specialty

Completion of approved residency program

Documentation of additional training in health plan review, utilization management and quality programs

Certificate of Medical Management

MBA, MHA, MPH – health administration or related field

3 or more years

Three to…