• Physician Pharmacy Reviewer

    Corewell Health (Grand Rapids, MI)


    Job Summary

    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.

     

    #CorewellHealthCareers

    How Corewell Health cares for you

    + Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here (https://careers.corewellhealth.org/us/en/benefits-new) .

    + On-demand pay program powered by Payactiv

    + Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!

    + Optional identity theft protection, home and auto insurance, pet insurance

    + Traditional and Roth retirement options with service contribution and match savings

    + Eligibility for benefits is determined by employment type and status

     

    Primary Location

     

    SITE - Priority Health - 1231 E Beltline - Grand Rapids

     

    Department Name

     

    PH - Medical Affairs

     

    Employment Type

     

    Part time

     

    Shift

     

    Day (United States of America)

     

    Weekly Scheduled Hours

     

    20

    Hours of Work

    8:00 a.m. to 5:00 p.m.

     

    Days Worked

     

    Monday to Friday

     

    Weekend Frequency

    N/A

    CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.

     

    Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

     

    Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

     

    An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

     

    You may request assistance in completing the application process by calling 616.486.7447.