Medication Access Specialist (Remote)-Community Pharmacy

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The Medication Access Specialist provides pharmacist- or nurse-level clinical support for the UHealth medication access program, so patients get timely, clinically appropriate access to high-cost, specialty, infusion, and cell and gene therapies. The specialist applies clinical judgment to the medical necessity components of prior authorizations, appeals, and peer-to-peer reviews, and is the clinical resource for Medication Access Coordinators (MAC I to IV).

The role is open to two licensure pathways: pharmacist (RPh) or registered nurse (RN). RN-pathway incumbents perform clinical case review and utilization management consistent with the Florida Nurse Practice Act and escalate pharmacological or drug-specific questions to a supervising pharmacist. Work is performed remotely using secure UHealth systems.

Reporting to the Manager, Medication Access, the specialist partners with prescribers, payer medical directors, and the coordinator team to resolve complex coverage determinations, support site-of-care and bridging therapy decisions, and identify denial and payer policy trends that shape access strategy. All duties are performed within the scope of the incumbent's license.

CORE JOB FUNCTIONS                                                                                           

·       Reviews medical necessity documentation, clinical criteria, and therapy appropriateness for complex or high-cost prior authorization and appeal requests referred by coordinators.

·       Serves as clinical reviewer of record for peer-to-peer reviews and complex appeals, presenting clinical rationale to prescribers and payer medical directors.

·       Drafts and reviews letters of medical necessity with prescribers and the clinical pharmacy and nursing teams.

·       Recommends clinically appropriate alternative therapies with prescribers when initial requests are denied.

·       Provides clinical rationale for site-of-care determinations aligned with clinical appropriateness, payer policy, and prescriber intent.

·       Supports cell and gene therapy access (for example, CAR-T), including bridging therapy options during manufacturing and coordination of CRS monitoring logistics with the treatment team, escalating clinical concerns promptly.

·       Provides case consultation to MAC I to IV coordinators on denials, ambiguous coverage criteria, and unusual clinical circumstances, and supports the Manager with coordinator training and competency development.

·       Conducts retrospective reviews of payment denials and underpayments to identify trends and recommend process, policy, and contract improvements.

·       Maintains current knowledge of payer prior authorization criteria, step therapy, and formulary policies, and provides clinical input to P&T and related workgroups.

·       Documents clinical interventions, recommendations, and outcomes to support quality reporting and program metrics.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

CORE QUALIFICATIONS                                                                                           

Education:

·       One of the following, consistent with the licensure pathway: Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy (BS Pharmacy); or Bachelor of Science in Nursing (BSN) or higher nursing degree.

Certification and Licensing:

·       Active, unrestricted Florida license in good standing as a Pharmacist (RPh) or Registered Nurse (RN) required.

·       Pharmacist pathway: board certification preferred (for example, BCPS or BCOP) or Certified Specialty Pharmacist (CSP).

·       RN pathway: Certified Case Manager (CCM), Oncology Certified Nurse (OCN), or Certified Registered Nurse Infusion (CRNI) preferred.

Experience:

Two to four years of pharmacist or registered nurse experience required, preferably in specialty pharmacy, oncology or infusion nursing, prior authorization and appeals, case management, or medication access.

Knowledge, Skills and Abilities:

·       Working knowledge of payer prior authorization and appeals processes, medical necessity criteria, and specialty and high-cost drug policy.

·       Clinical knowledge of specialty, oncology, infusion, and cell and gene therapies.

·       Familiarity with infusion and site-of-care programs, REMS requirements, and manufacturer hub and patient support programs preferred.

·       Strong written and verbal communication for peer-to-peer reviews, appeals, and coordinator consultation.

·       Ability to work within the scope of the incumbent's license (RPh or RN) and escalate questions outside that scope to the appropriate licensed colleague.

·       Ability to analyze denial and reimbursement data and translate trends into recommendations.

·       Ability to work independently in a remote setting; working knowledge of HIPAA and confidentiality requirements.

·       Clear written and oral communication in English.

This is a core job profile description and is not reflective of all duties that may be assigned to a specific position in each individual department. The above statements are intended to describe the general nature and primary responsibilities of this core job profile. Specific duties and tasks may vary based upon departmental needs. Other duties may be assigned to the above consistent with the knowledge, skills, and abilities required for the job.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.

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