Clinical Authorization Pharmacist

Thank you for your interest. Please note, the purpose of this posting is to recruit for on-going and future positions.

About City of Hope

Join the transformative team at City of Hope, where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and treatment facilities in Atlanta, Chicago and Phoenix. Our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today.

The clinical authorization pharmacist is a licensed pharmacist who utilizes their clinical oncology training to support non-pharmacy stakeholders such as Financial Clearance and Revenue Cycle to ensure medical benefits claim for infusion services are approved by payers. The clinical authorization pharmacist will provide support to the Financial Clearance team to ensure complete and appropriate pre-authorization requests are sent out to payers and mitigate the occurrence of rework needed and/or payor rejection. This role will also support Revenue Cycle team members to ensure denied claims are successfully appealed and preventable write-offs are mitigated. Additionally, clinical authorization pharmacist will work with the pharmacy leadership team to develop novel or streamline current processes aimed at achieving optimal COH and payor formulary adherence, clinical pathway adherence, and other opportunities as identified by pharmacy leadership.

As a successful candidate, you will:

• Collaborates with Financial Clearance team members, providers, nurses, clinical pharmacists and other clinical staff to ensure authorization requests are appropriate prior to submission to payers.
• Ensure payor guideline adherence by careful review of payor portals such as AIM, Evicore, or similar payor platforms.
• Review treatment plan orders to ensure adequate medical necessity documentation, payor formulary adherence, COH formulary adherence, and optimal supportive care medication utilization.
• Provide quality assurance review of authorization requests to ensure billable units, formulation, diagnosis code alignment are appropriate, and flag non-covered services.
• Use evidence based clinical justification to participate in peer-to-peer review for authorization denial appeals as necessary.
• Focus on mitigating preventable write-offs downstream.
• Review claims denial report and support appeal efforts.
• Use evidence-based clinical justification to draft claims denial appeals as necessary.
• Provide consultative support as necessary to ensure appropriate claims submission.
• Maintains compliance with all rules and regulations governing the practice of Pharmacy and City of Hope policies and procedures.
• Performs other duties as assigned by the Leadership Team.

Your qualifications should include:  

• Graduate of ACPE-accredited Pharmacy School or School with ACPE accreditation pending
• 1 year of clinical oncology pharmacy experience or equivalent
• ASHP Accredited Residency - preferred
• Current CA Pharmacist License
• American Heart Association BLS certification