Curative
Chief Medical Officer @ Curative | Harvard Business School Alumni
Curative is reimagining health insurance with zero out-of-pocket costs by reducing barriers to care. We strive to create a better healthcare experience for our members, providing easy and intuitive access to the care they need. Curative is rapidly growing and raising the bar in what people expect from a health plan.
This remote position requires an active RPh license in the state of residence.
Essential Duties And Responsibilities
Performs Prior Authorization reviews and coverage determinations as defined by pharmacy benefit design and established clinical treatment guidelines.
Manages all levels of clinical review from Adverse Determination, Appeals, and IRO.
Supports and manages health plan operations and ensures PBM aligns with benefit design.
Writes, reviews, and updates PA guidelines to support the P&T committee and pharmacy benefit design.
Acts as support to pharmacy technician and provides training and education where needed.
Meets assigned metrics and TAT as defined by regulatory requirements within state or lines of business.
Supports disease management initiatives such as adherence, weight management, and diabetes.
Collaborates with Medical Directors and other interdepartmental staff to communicate pharmacy strategies and clinical programs or initiatives.
Develops applicable desktop procedures for supporting PA applications.
Reviews and resolves complaints made by members and providers regarding prior authorization, formulary, or pharmacy services.
Participates in support of the Pharmacy and Therapeutics Meeting to review and keep current on the drug formulary.
Performs appropriate literature and clinical research.
Knowledge of utilizing LexiComp, Facts and Comparisons, Micromedex, UptoDate, National guidelines, NCCN, etc.
Collaborates to create clear communication to members and/or providers on prior authorization determinations.
Works in partnership with pharmacy staff to assist in the implementation of utilization management programs.
Works in collaboration with the Program Manager to help with workflows and operational efficiencies.
Evaluates opportunities for operational or process improvements.
Supports and manages other related health plan operations.
Works adhering to US regulatory and Quality System requirements (21 CFR 820, etc.).
Assumes and performs other duties as assigned.
Work hours Mon-Friday and some Saturdays.
Qualifications Required Qualifications
Strong analytical skills and detail oriented.
Ability to work independently with minimal supervision.
Understanding of claims processing and claims edits.
Intermediate level proficiency with MS Office applications—Word, Power Point, Excel, and Access.
Intermediate to advanced pharmacy drug recognition.
Ability to work in a dynamic and fast‑paced environment.
2 years of experience with specialty medications or prior authorization.
1 year of experience with PBM or Managed Care setting.
Preferred Qualifications
3 years as practicing pharmacist or 1 year as PGY‑1 resident.
2 years’ experience in a Managed Care Setting.
Knowledge of Medispan or First Data Bank and drug classification system.
Understanding of Drug‑Cost Analysis.
BCPS or CSP certification.
Education & Experience
Doctor of Pharmacy (Pharm D) degree.
Certificates, Licenses, Registrations Must possess an active RPh license within state of residence.
Work Environment
Regularly required to sit; use hands to handle or feel; talk; and hear.
Expected travel: 15%–20% of the time.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Administrative
Industries Hospitals and Health Care
#J-18808-Ljbffr
This remote position requires an active RPh license in the state of residence.
Essential Duties And Responsibilities
Performs Prior Authorization reviews and coverage determinations as defined by pharmacy benefit design and established clinical treatment guidelines.
Manages all levels of clinical review from Adverse Determination, Appeals, and IRO.
Supports and manages health plan operations and ensures PBM aligns with benefit design.
Writes, reviews, and updates PA guidelines to support the P&T committee and pharmacy benefit design.
Acts as support to pharmacy technician and provides training and education where needed.
Meets assigned metrics and TAT as defined by regulatory requirements within state or lines of business.
Supports disease management initiatives such as adherence, weight management, and diabetes.
Collaborates with Medical Directors and other interdepartmental staff to communicate pharmacy strategies and clinical programs or initiatives.
Develops applicable desktop procedures for supporting PA applications.
Reviews and resolves complaints made by members and providers regarding prior authorization, formulary, or pharmacy services.
Participates in support of the Pharmacy and Therapeutics Meeting to review and keep current on the drug formulary.
Performs appropriate literature and clinical research.
Knowledge of utilizing LexiComp, Facts and Comparisons, Micromedex, UptoDate, National guidelines, NCCN, etc.
Collaborates to create clear communication to members and/or providers on prior authorization determinations.
Works in partnership with pharmacy staff to assist in the implementation of utilization management programs.
Works in collaboration with the Program Manager to help with workflows and operational efficiencies.
Evaluates opportunities for operational or process improvements.
Supports and manages other related health plan operations.
Works adhering to US regulatory and Quality System requirements (21 CFR 820, etc.).
Assumes and performs other duties as assigned.
Work hours Mon-Friday and some Saturdays.
Qualifications Required Qualifications
Strong analytical skills and detail oriented.
Ability to work independently with minimal supervision.
Understanding of claims processing and claims edits.
Intermediate level proficiency with MS Office applications—Word, Power Point, Excel, and Access.
Intermediate to advanced pharmacy drug recognition.
Ability to work in a dynamic and fast‑paced environment.
2 years of experience with specialty medications or prior authorization.
1 year of experience with PBM or Managed Care setting.
Preferred Qualifications
3 years as practicing pharmacist or 1 year as PGY‑1 resident.
2 years’ experience in a Managed Care Setting.
Knowledge of Medispan or First Data Bank and drug classification system.
Understanding of Drug‑Cost Analysis.
BCPS or CSP certification.
Education & Experience
Doctor of Pharmacy (Pharm D) degree.
Certificates, Licenses, Registrations Must possess an active RPh license within state of residence.
Work Environment
Regularly required to sit; use hands to handle or feel; talk; and hear.
Expected travel: 15%–20% of the time.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Administrative
Industries Hospitals and Health Care
#J-18808-Ljbffr