administrative support clerk - case management

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administrative support clerk - case management Jobs in Ohio

clinical case manager, behavioral health Jobs in Ohio

clinical case manager, behavioral health

clinical pharmacist - managed care Jobs in Ohio

clinical pharmacist - managed care

pbm client experience manager Jobs in Ohio

pbm client experience manager

telephonic case manager

clinical case manager behavioral health

CVS Health

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.
Position Summary:
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. 
Assessment of Members:<ul><li>
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member&rsquo;s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member&rsquo;s benefit plan and available internal and external programs/services.</li><li>
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.</li><li>
Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.</li><li>
Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.</li></ul>
Enhancement of Medical Appropriateness and Quality of Care:<ul><li>
Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member&rsquo;s needs to ensure appropriate administration of benefits</li><li>
Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes</li><li>
Identifies and escalates quality of care issues through established channels</li><li>
Ability to speak to medical and behavioral health professionals to influence appropriate member care.</li><li>
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health</li><li>
Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.</li><li>
Helps member actively and knowledgably participate with their provider in healthcare decision-making</li><li>
Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.</li></ul> 
Monitoring, Evaluation and Documentation of Care<ul><li>
In collaboration with the member and their care team develops and monitors established plans of care to meet the member&rsquo;s goals</li><li>
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.</li><li>
Ability to take and manage crisis calls.</li></ul> 
Required Qualifications:<ul><li>
Unencumbered Independent Behavioral Health clinical license in the state where they reside and work:</li></ul><h3 class="jobSectionHeader">
Licensed Mental Health Counselor (LMHC)</h3><h3 class="jobSectionHeader">
Licensed Clinical Social Worker (LCSW)</h3><h3 class="jobSectionHeader">
Licensed Independent Social Worker (LISW)</h3><h3 class="jobSectionHeader">
Licensed Marital and Family Therapist (LMFT)</h3><h3 class="jobSectionHeader">
Licensed Professional Counselor (LPC)</h3><ul><li>
3+ years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility</li><li>
3+ years minimum of Behavioral Health experience</li><li>
Applicants must be willing to work standard business hours in EST or CST.</li></ul> 
Preferred Qualifications<ul><li>
Case management and discharge planning experience
</li><li>Crisis intervention skills
</li><li>Managed care/utilization review experience
</li><li>Ability to take and manage crisis calls</li></ul>
Education
Minimum of a Master&rsquo;s degree in Behavioral/Mental Health or related field
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$54,095.00 - $142,576.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 05/02/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Clinical Case Manager, Behavioral Health

Sedgwick

<div>By joining Sedgwick, you'll be part of something truly meaningful. It&rsquo;s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there&rsquo;s no limit to what you can achieve.
Newsweek Recognizes Sedgwick as America&rsquo;s Greatest Workplaces National Top Companies
Certified as a Great Place to Work&reg;
Fortune Best Workplaces in Financial Services &amp; Insurance
Telephonic Case Manager
<div>PRIMARY PURPOSE OF THE ROLE: While partnering with the injured worker, employer, and medical providers, create a case management strategy to facilitate medical recovery and a successful return to work through advocacy, communication and coordination of medical services.
ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.
<ul><li>Apply your medical/clinical or rehabilitation knowledge and experience to assist in the management of complex medical conditions, treatment planning and recovery from illness or injury.
</li><li>Work in the best of both worlds - a rewarding career making an impact on the health and lives of others, and a remote work environment.
</li><li>Enjoy flexibility and autonomy in your daily work, your location, and your career path while advocating for the most effective and efficient medical treatment for injured employees in a non-traditional setting.
</li><li>Enable our Caring counts&reg; mission supporting injured employees from some of the world&rsquo;s best brands and organizations.
</li><li>Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service.
</li><li>Celebrate your career achievements and each other through professional development opportunities, continuing education credits, team building initiatives and more.
</li><li>Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs.
</li></ul>ESSENTIAL RESPONSIBLITIES MAY INCLUDE
<ul><li>Performs initial and ongoing clinical assessment via telephone calls to evaluate the injured worker's injury, medical treatment, psychosocial needs, cultural implications and support systems.
</li><li>Effectively communicates and builds relationships with the claims&rsquo; examiner, client, injured worker, attorney and supervisor.
</li><li>Identifies issues related to delayed recovery and/or return to work and problem solves with a creative thinking approach
</li><li>Negotiates treatment and disability duration with providers through use of medical and disability duration guidelines, adhering to quality.
</li><li>Identifies opportunities to expedite care for cost containment and timely medical recovery.
</li><li>Provides recommendations for alternate clinical resources to support claim resolution.
</li><li>Maintains client's privacy and confidentiality, promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards.
</li></ul>EDUCATION AND LICENSING
Current unrestricted RN license(s) in a state or territory of the United States required. Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred. Certification in case management, rehabilitation nursing or a related specialty is highly preferred. 
TAKING CARE OF YOU BY
<ul><li>Offering flexibility and autonomy.
</li><li>Supporting meaningful work that promotes critical thinking and problem solving.
</li><li>Providing on-going learning and professional growth opportunities.
</li><li>Promoting a strong team environment and a culture of support.
</li><li>Recognizing your successes and celebrating your achievements.
</li><li>Thrives when everyone is working towards the same vision/goals.
</li><li>We offer a diverse and comprehensive benefits including medical, dental vision, 401K, PTO and more beginning your first day.
</li></ul>NEXT STEPS
If your application is selected to advance to the next round, recruiter will be in touch.
As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $72,000 - $75,000/year. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.
#nurse #telephoniccasemanager
</div>Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
<h2 class="jobSectionHeader">If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.</h2></div>

Telephonic Case Manager

Medical Mutual of Ohio

<div><div>**Medical Mutual employees must submit their applications through MySource.</div>
<div></div>
<div>**This is a remote-based role, and we are currently seeking candidates located in Ohio.</div><div> 
</div>Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Job Summary:
Under limited supervision, promotes effective use of, and provides appropriate resources and assistance to members managing their health care across the continuum of care. Applies evidence-based criteria and benefit interpretations to make coverage decisions. Collaborates with providers, members, and various internal departments to effectively direct care to quality cost-effective network providers at the appropriate level of care.

Responsibilities:
<ul>
<li>Conducts pre-certification of basic to complex outpatient services, surgical and diagnostic procedures, and out of network services to ensure compliance with medical policy, member eligibility, benefits, and contracts.</li>
<li>Evaluates clinical information using established national decision support criteria, company policies, and individual patient considerations to ensure the provisions of safe, timely, and appropriately covered healthcare services.</li>
<li>Promotes effective resource management by directing member care to accessible cost- effective network providers and coordinates services at appropriate level of care. Coordinates with other Pharmacy and Care Management departments to facilitate the timely provision of covered health care services.</li>
<li>Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Assists Claims and/or Customer Care Departments as applicable.</li>
<li>Keeps up to date on utilization management regulations, policies, and practices, including applicable coding.</li>
<li>If assigned to Preceptor/Trainer task: Orients, trains, and provides guidance to more junior or less experienced staff. Supports implementation of new procedures, processes, or clinical systems.</li>
<li>Performs other duties as assigned.</li>
</ul>
Qualifications:

Education and Experience:
<ul>
<li>Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor&rsquo;s degree preferred.</li>
<li>3 years of experience as a Registered Nurse with a combination of clinical and utilization/case management experience, preferably in the health insurance industry.</li>
<li>Acute care Medical/Surgical/Critical Care and ambulatory care experience preferred.</li>
</ul>
Professional Certification(s):
<ul>
<li>Registered Nurse with current State of Ohio or multistate unrestricted license.</li>
</ul>
Technical Skills and Knowledge:
<ul>
<li>Strong knowledge of health insurance benefits and network plan designs.</li>
<li>Knowledge of, and the ability to apply fundamental concepts related to HIPAA compliance and related regulations.</li>
<li>Ability to apply knowledge of health plans and industry trends to achieve positive outcomes.</li>
<li>Knowledge of clinical practices, members&rsquo; specific health plan benefits, and efficient care delivery processes.</li>
<li>Intermediate Microsoft Office skills and proficiency navigating windows and web based systems.</li>
</ul>
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:
<ul>
<li>We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.</li>
<li>Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.</li>
<li>On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.</li>
<li>Discounts at many places in and around town, just for being a Medical Mutual team member.</li>
<li>The opportunity to earn cash rewards for shopping with our customers.</li>
<li>Business casual attire, including jeans.</li>
</ul>
Excellent Benefits and Compensation:
<ul>
<li>Employee bonus program.</li>
<li>401(k) with company match up to 4% and an additional company contribution.</li>
<li>Health Savings Account with a company matching contribution.</li>
<li>Excellent medical, dental, vision, life and disability insurance &mdash; insurance is what we do best, and we make affordable coverage for our team a priority.</li>
<li>Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.</li>
<li>Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.</li>
<li>After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.</li>
</ul>
An Investment in You:
<ul>
<li>Career development programs and classes.</li>
<li>Mentoring and coaching to help you advance in your career.</li>
<li>Tuition reimbursement up to $5,250 per year, the IRS maximum.</li>
<li>Diverse, inclusive and welcoming culture with Business Resource Groups.</li>
</ul>
About Medical Mutual:

Medical Mutual&rsquo;s status as a mutual company means we are owned by our policyholders, not stockholders, so we don&rsquo;t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There&rsquo;s a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We&rsquo;re not just one of the largest health insurance companies based in Ohio, we&rsquo;re also the longest running. Founded in 1934, we&rsquo;re proud of our rich history with the communities where we live and work.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.

#LI-CS1 #LI-REMOTE</div>

Prior Authorization Nurse Reviewer II

Montgomery County, OH

<div><div><div><h2 class="jobSectionHeader">Position Overview</h2></div>
<div>POSITION SUMMARY:
The Administrative Support Clerk &ndash; Case Management serves in the Case Management Department and reports to the Case Management Manager.
The Administrative Support Clerk &ndash; Case Management is responsible for providing support to the Case Management team, which requires general clerical and administrative duties.</div>
<div><h2 class="jobSectionHeader">Summary of Job Duties</h2></div>
<div>ESSENTIAL DUTIES AND RESPONSIBILITIES:
The essential duties and responsibilities of the position are as follows:<ul><li>
Answers telephone inquiries, directs callers to appropriate offices, and provides information to requesting parties.</li><li>
Greets defendants, attorneys and the general public, and directs them to the appropriate person or location. Accesses computer for court appearance information.</li><li>
Monitors supplies, collects and distributes mail, maintains orderly and clean reception area.</li><li>
Schedules conference rooms for court employees and various elected officials.</li><li>
Participates in training opportunities, court activities, projects, and committees as requested or required.</li><li>
Completes other duties and responsibilities as required.</li></ul></div> 

<div><h2 class="jobSectionHeader">Minimum Qualifications and Requirements</h2></div>
<div>REQUIRED KNOWLEDGE, ABILITIES, AND SKILLS:<div><ul><li>
Knowledge of: general office practices and procedures; court system processes and procedures; case management processes and procedures; grammar and sentence structure; spelling and punctuation.</li></ul></div><div></div><div><ul><li> 
Ability to: understand and apply work processes and procedures; establish work priorities; answer routine inquiries from officials and general public; resolve complaints calmly.</li></ul></div><div></div><div><ul><li> 
Skill in: analyzing information against established standards; operating a computer and general office equipment; application of job software programs, including spreadsheets and word processing; general typing.</li></ul></div><div></div> 
GENERAL EXPECTATIONS OF ALL COURT EMPLOYEES:
All court employees are expected to stay current in their areas of technical expertise; maintain attention to detail; exhibit good organizational skills; work effectively on own initiative and by cooperating with others; engage in active listening; speak and write clearly and concisely; demonstrate good manners, friendly demeanor, and professional behavior; uphold the policies, procedures, and practices of the court; maintain the confidentiality of sensitive and privileged information; and represent the court with honesty and integrity.
EDUCATION AND EXPERIENCE QUALIFICATIONS:
The position requires an appropriate combination of formal education, additional training and courses, and work experience. There is not an exact level or mixture of these elements to indicate one will necessarily be successful in, or qualify for, the position.
For example purposes only, an acceptable combination of qualifications for the position would include a bachelor&rsquo;s degree in public administration, business administration; criminal justice or related field, or an associate&rsquo;s degree in public administration, business administration, criminal justice or a related field and two years&rsquo; work experience.<div>
LICENSURE OR CERTIFICATION REQUIREMENTS:</div>
A valid state of Ohio motor vehicle operator&rsquo;s license is preferred in order to carry out job-related essential functions. Private insurance is required if private vehicle is employed for job-related functions.</div> 

<div><h2 class="jobSectionHeader">Supplemental Information</h2></div>
<div>SCOPE OF SUPERVISION:
The position requires no supervisory duties or responsibilities.
EQUIPMENT OPERATED:
Vehicle, computer, calculator, copier, fax, telephone, and other general office equipment.
WORK ENVIRONMENT AND USUAL PHYSICAL DEMANDS:
The following physical demands are typically exhibited by the incumbent performing the requirements of the position. These physical demands are not, and should not be construed to be, job qualification standards. They are illustrated to help the court, incumbent, and applicant for the position identify reasonable accommodations that may need to be made when an otherwise qualified person is unable to perform the job&rsquo;s essential functions because of a recognized disability covered by, and in accordance with, the requirements of the Americans with Disabilities Act.
While performing duties of this job, the employee regularly exhibits digital dexterity and eye-hand coordination when performing typing and other tasks. The employee frequently sits for extended periods of time, and occasionally stands and walks. Employee converses verbally with others in person and by telephone. Vision demands include close, relatively detailed vision when typing and using a computer screen. Job may involve operating and sitting in a vehicle.
This position description in no manner states or implies, and should not be construed as stating or implying, that it is a complete or exhaustive listing of the duties, responsibilities, qualifications for, and requirements of, an incumbent filling the position. The incumbent may be required to follow additional instructions and perform other duties required by a supervisor or designee.
The provisions of this position description do not constitute a contract, expressed or implied, and any provision contained in this description may be modified or revoked without notice.</div></div></div>

Administrative Support Clerk - Case Management

Medical Mutual

<div>
 <ul>
 <li>
 Medical Mutual employees must submit their applications through MySource.
 </li>
 <li>
 This is a remote-based role, and we are currently seeking candidates located in Ohio.
 
 
 </li>
 </ul>
 Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
 
 
 
 Clinical Pharmacist I
 
 
 
 
 
 Job Summary:
 
 
 
 
 As assigned, supports any of the following pharmacist specialty areas; formulary and policy development, intervention programs for commercial and Medicare programs, partnering with sales team, or health systems liaison. Develops and implements evidence based clinical programs to ensure that members receive the most clinically appropriate medication cost-effectively. Evaluates evidence and applies these principles to patient care.
 
 
 
 
 Responsibilities:
 
 
 
 
 <ul>
 <li>
 Based on assigned pharmacist specialty area, may include any of the following (% of time per function will vary):
 </li>
 <li>
 Develops policies and strategies to engage members and/or providers and help drive improvements in pharmaceutical care and pharmacy quality measures to decrease drug spend.
 </li>
 <li>
 Addresses Medicare STAR drugs (STATIN, RASA, and non-insulin diabetes) adherence gaps.
 </li>
 <li>
 Reviews drug/medical literature, clinical practice guidelines, quality measures, and available national guidelines to support formulary, drug policy or drug therapy interventions and creation of new initiatives.
 </li>
 <li>
 Contributes with PBM/vendor oversight activities including regular or ad-hoc audits of clinical programs.
 </li>
 <li>
 Collaborates with pharmacy team members in the development and implementation of programs to communicate and educate internal staff, external brokers, strategic health systems, pharmacy chains and provider groups.
 </li>
 <li>
 Performs Consumer Assessment of Healthcare Providers and Systems (CAHPS)-focused interventions to improve drug plan perception.
 </li>
 <li>
 Assists Sales in selling and renewing pharmacy services, or retaining business, by attending meetings, promoting pharmacy benefits and services, developing responses to Request for Proposal (RFP), recommending solutions to brokers and their clients, etc.
 </li>
 <li>
 Collaborates with pharmacy departments within the Company&rsquo;s strategic health systems, pharmacy chains and provider groups to implement programs which better engage members to improve overall medication quality performance and cost of care for attributed populations by facilitating regular interactions to build and support the clinical relationship.
 </li>
 <li>
 Assists in closing Medicare STARS-related gaps by completing Comprehensive Medication Reviews (CMRs), Medication Reconciliation Post-Discharge (MRPs), and In-Home Assessments (IHAs).
 </li>
 <li>
 Partners with internal departments including Medicare STARS, Clinical Quality Health Services, Provider Network Management, HEDIS, and Customer Care to develop and implement programs and clinical initiatives to support achievement of strategic goals.
 </li>
 <li>
 Builds and maintains and clinical knowledge and knowledge of prescription benefit trends.
 </li>
 <li>
 Performs other duties as assigned.
 
 
 </li>
 </ul>
 
 
 Qualifications:
 
 
 
 
 
 Education and Experience:
 
 
 
 <ul>
 <li>
 Doctor of Pharmacy (Pharm.D.) preferred. Bachelor of Pharmacy with relevant experience may be considered.
 </li>
 <li>
 Successful completion of internal Clinical Pharmacy Resident program, or 0 to 3 years of experience as a Clinical Pharmacist, or equivalent experience in a managed care pharmacy setting.
 </li>
 <li>
 Medicare/Medicaid experience preferred.
 
 
 </li>
 </ul>
 
 
 Professional Certification(s):
 
 
 
 
 <ul>
 <li>
 Registered Pharmacist with current unrestricted license from the appropriate State Board of Pharmacy.
 </li>
 <li>
 May be required to obtain Ohio State Board of Pharmacy license within 6 months of hire.
 
 
 </li>
 </ul>
 
 
 Technical Skills And Knowledge:
 
 
 
 
 <ul>
 <li>
 Understanding of managed care pharmacy, including formulary design/management, drug utilization management, and/or quality assurance programs.
 </li>
 <li>
 Knowledge of medical/pharmacy terminology/coding and specialty drug management.
 </li>
 <li>
 Good clinical acumen.
 </li>
 <li>
 Microsoft Office skills specifically Excel and Pharmacy Benefit Management (PBM) systems; basic proficiency with Visio and/or Access.
 </li>
 <li>
 Ability to present clinical information to various internal and external audiences.
 
 
 </li>
 </ul>
 
 Clinical Pharmacist II
 
 
 
 
 
 Responsibilities:
 
 
 
 
 <ul>
 <li>
 Based on assigned pharmacist specialty area, may include any of the following (% of time per function will vary):
 </li>
 <li>
 Develops policies and strategies to engage members and/or providers and help drive improvements in pharmaceutical care and pharmacy quality measures to decrease drug spend.
 </li>
 <li>
 Addresses Medicare STAR drugs (STATIN, RASA, and non-insulin diabetes) adherence gaps.
 </li>
 <li>
 Reviews drug/medical literature, clinical practice guidelines, quality measures, and available national guidelines to support formulary, drug policy or drug therapy interventions and creation of new initiatives.
 </li>
 <li>
 Interacts with PBM/vendor oversight activities including regular or ad-hoc audits of clinical programs.
 </li>
 <li>
 Develops and implements programs to communicate and educate internal staff, external brokers, strategic health systems, pharmacy chains and provider groups.
 </li>
 <li>
 Performs Consumer Assessment of Healthcare Providers and Systems (CAHPS)-focused interventions to improve drug plan perception.
 </li>
 <li>
 Promotes the value-add of the Company&rsquo;s pharmacy services with internal and external stakeholders. Develops relationships and partnerships to support health systems engagement or sales efforts.
 </li>
 <li>
 Assists Sales in selling and renewing pharmacy services, or retaining business, by attending meetings, promoting pharmacy benefits and services, developing responses to Request for Proposal (RFP), recommending solutions to brokers and their clients, etc.
 </li>
 <li>
 Collaborates with pharmacy departments within the Company&rsquo;s strategic health systems, pharmacy chains and provider groups to implement programs which better engage members to improve overall medication quality performance and cost of care for attributed populations by facilitating regular interactions to build and support the clinical relationship.
 </li>
 <li>
 Assists in closing Medicare STARS-related gaps by completing Comprehensive Medication Reviews (CMRs), Medication Reconciliation Post-Discharge (MRPs), and In-Home Assessments (IHAs).
 </li>
 <li>
 Partners with internal departments including Medicare STARS, Clinical Quality Health Services, Provider Network Management, HEDIS, and Customer Care to develop and implement programs and clinical initiatives to support achievement of strategic goals.
 </li>
 <li>
 May orient, train, and assist new hires, residents, and junior level Pharmacists. Maintains and shares clinical knowledge and knowledge of prescription benefit trends.
 </li>
 <li>
 Performs other duties as assigned.
 
 
 </li>
 </ul>
 
 
 Education And Experience:
 
 
 
 
 <ul>
 <li>
 Doctor of Pharmacy (Pharm.D.) preferred. Bachelor of Pharmacy with relevant experience may be considered.
 </li>
 <li>
 3 years of experience as a Clinical Pharmacist or equivalent experience in a managed care pharmacy setting.
 </li>
 <li>
 Medicare/Medicaid experience preferred.
 
 
 </li>
 </ul>
 
 
 Technical Skills And Knowledge:
 
 
 
 
 <ul>
 <li>
 Understanding of managed care pharmacy, including formulary design/management, drug utilization management, and/or quality assurance programs.
 </li>
 <li>
 Knowledge of medical/pharmacy terminology/coding and specialty drug management.
 </li>
 <li>
 Good clinical acumen and strategic analysis skills.
 </li>
 <li>
 Microsoft Office skills specifically Excel and Pharmacy Benefit Management (PBM) systems; basic proficiency with Visio and/or Access.
 </li>
 <li>
 Ability to present clinical information to various internal and external audiences.
 
 
 </li>
 </ul>
 
 Sr Clinical Pharmacist
 
 
 
 
 
 Job Summary:
 
 
 
 
 Applies a thorough understanding of clinical pharmacy programs including formulary design, prescription benefit trends, and translates complex clinical information into actionable strategies. Administers formulary design and drug policy within the clinical systems of the Pharmacy Benefit Manager (PBM). Keeps apprised of prescription benefit trends and pipeline, ensuring programs are set for success as the landscape of pipeline evolves. Presents, translates, and communicates complex clinical information for diverse group benefit plan audiences.
 
 
 
 
 Responsibilities:
 
 
 
 
 <ul>
 <li>
 Provides clinical support for formulary and policy development in the administration of pharmacy benefits. Identifies new opportunities for drug management, including safety programs, and medical/pharmacy cost savings.
 </li>
 <li>
 Collaborates with Chief Medical Officer, other Physician leadership, and related staff to perform utilization review of drugs to develop drug medical policies, research new drugs for possible utilization, education staff/customers and identify administration of those policies.
 </li>
 <li>
 Interprets standards published by national accrediting bodies, gathers and documents supporting evidence demonstrating compliance with said standards. Collaborates with external delegate(s) and Pharmacy Management department with regard to accreditation standard oversight.
 </li>
 <li>
 Represents the department or division in activities or projects as assigned by management.
 </li>
 <li>
 Provides oversight of PBM or third-party vendors by conducting regular audits of clinical program implementation and operations.
 </li>
 <li>
 Conducts internal and external appeal reviews and works with medical directors to decision cases and complete Independent Review Organization (IRO) submissions.
 </li>
 <li>
 May lead projects for existing staff and acts as a resource to newly hired staff, supporting management with training, assigned projects, and goals.
 </li>
 <li>
 Reviews drug/medical literature, clinical practice guidelines, and available national guidelines to support drug policy development and consultation over various medical and pharmacy clinical programs
 </li>
 <li>
 Orients, trains, and assists new hires, residents, and junior level Pharmacists. Develops and maintains policies and procedures to support team as needed. Maintains and shares knowledge of prescription benefit trends.
 </li>
 <li>
 Performs other duties as assigned.
 
 
 </li>
 </ul>
 
 
 Education And Experience:
 
 
 
 
 <ul>
 <li>
 Doctor of Pharmacy (Pharm.D.) preferred. Bachelor of Pharmacy with relevant experience may be considered.
 </li>
 <li>
 5 years of experience as a Clinical Pharmacist or equivalent experience in a managed care pharmacy setting.
 
 
 </li>
 </ul>
 
 
 Technical Skills And Knowledge:
 
 
 
 
 <ul>
 <li>
 Comprehensive understanding of managed care pharmacy, including formulary design/management, drug utilization management, and/or quality assurance programs.
 </li>
 <li>
 Knowledge of medical/pharmacy terminology/coding and specialty drug management.
 </li>
 <li>
 Strong clinical acumen and strategic analysis skills.
 </li>
 <li>
 Advanced Microsoft Office skills specifically Excel and Pharmacy Benefit Management (PBM) systems; basic proficiency with Visio and/or Access.
 </li>
 <li>
 Ability to present clinical information to various internal and external audiences.
 
 
 </li>
 </ul>
 
 A Great Place To Work:
 
 
 
 Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
 
 
 <ul>
 <li>
 We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
 </li>
 <li>
 Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
 </li>
 <li>
 On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
 </li>
 <li>
 Discounts at many places in and around town, just for being a Medical Mutual team member.
 </li>
 <li>
 The opportunity to earn cash rewards for shopping with our customers.
 </li>
 <li>
 Business casual attire, including jeans.
 
 
 </li>
 </ul>
 
 Excellent Benefits And Compensation:
 
 
 
 <ul>
 <li>
 Employee bonus program.
 </li>
 <li>
 401(k) with company match up to 4% and an additional company contribution.
 </li>
 <li>
 Health Savings Account with a company matching contribution.
 </li>
 <li>
 Excellent medical, dental, vision, life and disability insurance &mdash; insurance is what we do best, and we make affordable coverage for our team a priority.
 </li>
 <li>
 Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
 </li>
 <li>
 Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
 </li>
 <li>
 After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
 
 
 </li>
 </ul>
 
 An Investment In You:
 
 
 
 <ul>
 <li>
 Career development programs and classes.
 </li>
 <li>
 Mentoring and coaching to help you advance in your career.
 </li>
 <li>
 Tuition reimbursement up to $5,250 per year, the IRS maximum.
 </li>
 <li>
 Diverse, inclusive and welcoming culture with Business Resource Groups.
 
 
 </li>
 </ul>
 
 About Medical Mutual:
 
 
 
 Medical Mutual&rsquo;s status as a mutual company means we are owned by our policyholders, not stockholders, so we don&rsquo;t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
 
 
 There&rsquo;s a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.
 
 
 We&rsquo;re not just one of the largest health insurance companies based in Ohio, we&rsquo;re also the longest running. Founded in 1934, we&rsquo;re proud of our rich history with the communities where we live and work.
 
 
 
 We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
 
 
 
</div>

Clinical Pharmacist - Managed Care

UC Health

<div>UC Health is hiring a Full Time Business Intell Analyst
The purpose of this position is to support organizational needs for business intelligence, data reporting, and related metrics to inform decision-making, planning, and continuous improvement across UC Health. Responsibilities revolve around the collection, manipulation and dissemination of data to support the needs of decision-makers at all levels of the organization. This position will need to have a clear understanding of the data and work with key stakeholders in order to validate accurate results and reconcile discrepancies when necessary.
About UC Health
UC Health is an integrated academic health system serving Greater Cincinnati and Northern Kentucky. In partnership with the University of Cincinnati, UC Health combines clinical expertise and compassion with research and teaching&mdash;a combination that provides patients with options for even the most complex situations. Members of UC Health include: UC Medical Center, West Chester Hospital, University of Cincinnati Physicians and UC Health Ambulatory Services (with more than 900 board-certified clinicians and surgeons), Lindner Center of HOPE and several specialized institutes including: UC Gardner Neuroscience Institute and the University of Cincinnati Cancer Center. Many UC Health locations have received national recognition for outstanding quality and patient satisfaction. Learn more at uchealth.com.
Analytics Development and Support:<ul><li>
Supports information requests from inception to delivery, translating client requirements into appropriate reporting objects that tell a story with data including, but not limited to: analytic scorecards, dashboards, and reports.</li><li>
Provides solutions and alternatives to problems/issues including adhoc reports to support offered solutions.</li><li>
Executes reporting design changes according to established procedures.</li><li>
Provides maintenance support for all queries or reports.</li><li>
Provides timely and accurate support to resolve reporting errors and user reported problems.</li><li>
Utilizes and adheres to production support standards and promotion process.</li><li>
Acts as a resource / subject matter expert for the UC Health Departments.</li><li>
Responsible for monitoring data quality of related reporting datasets.</li><li>
Work with data requestor or stakeholder to validate the results.</li><li>
Determines and manages workload priorities.</li></ul>
Coordination:<ul><li>
Assesses and escalates user requests and issues.</li><li>
Works with programming teams on application development.</li></ul>
Testing and Documentation:<ul><li>
Provides documented solution to problems/issues.</li><li>
Performs complete testing of reports and validates application requirements are met.</li></ul>
Project Support:<ul><li>
Provides task level detail for project plans, including suggested schedules.</li><li>
Provides accurate and timely individual status reports.</li><li>
Documents and ensures timely resolution of project issues.</li><li>
Coordinates effectively with team members.</li><li>
Supports the institution&rsquo;s internal and external, strategic and operational reporting needs</li><li>
Informs management of all issues that are impacting or will impact assignment.</li><li>
Assists with regulatory requirements.</li><li>
Assists with external surveys.</li></ul>
Customer Relationship:<ul><li>
Builds consultative relationships, establishing value for the department as a key partner for producing high-quality, actionable information that meets the needs of decision-makers at all levels of the organization.</li><li>
Conveys technical messages in layman terms so that the receiver can understand, regardless of their technical aptitude.</li><li>
Provides consults to end users.</li></ul>
Other duties assigned by Manager:<ul><li>
Provides occasional backup for other duties as needed.</li></ul><ul><li>
Minimum Required: Bachelors Degree - Business Intelligence/Analytics related field.</li><li>
Preferred: Masters Degree - Epic Data (Caboodle / Clarity) certified within six months.</li><li>
Minimum Required: 1 - 2 Years equivalent experience</li><li>
4 years equivalent experience can substitute for a BA/BS degree.</li></ul>
Join our team to BE UC Health. Be Extraordinary. Be Supported. Be Hope. Apply Today!
At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.
As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors. UC Health is an EEO employer.</div>

Business Intell Analyst, Data & Analytics, Full-time, First Shift

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.
A Brief Overview
Administers operational support to clinical pharmacy staff. Conducts outreach to providers, pharmacists, and members. Supports day-to-day processes, reviews data, and documents relevant interactions. 
Position Summary
Primary responsibility is supporting Formulary Alternative Outreach Program for Medicare Part D. The Clinical Support Technician will support the operations of the Retro DUR (Drug Utilization Review)/Scorable Action Items (SAI) Clinical Pharmacy staff. This will include outreach calls to providers, pharmacists, and members. Responsibilities also include managing day-to-day processes, analyzing data, organizing and documenting all relevant interactions.<ul><li>
Executes both routine and non-routine business support tasks for the Clinical Pharmacy Support area under limited supervision, referring deviations from standard practices to managers.</li><li>
Follows area protocols, standards, and policies to provide effective and timely support.</li><li>
Conducts reviews to ensure members receive the appropriate therapy as approved by the provider, determines therapy timelines, and determines claim appropriateness.</li><li>
Initiates education for providers and pharmacies on medication options, enhancements, and alternative therapy options for members.</li><li>
Communicates with pharmacies to verify claim information and reverse unnecessary claims.</li><li>
Ability to solve problems and make decisions independently</li><li>
4+ years&rsquo; work experience</li><li>
Responsible for making prescriber and or pharmacy outreach which includes reviewing formulary vs. non-formulary prescription claims.</li><li>
Ensure member is receiving the appropriate therapy as approved by the provider and determine length of therapy and establish if current claims are appropriate.</li><li>
Review therapeutic duplication data and contact providers and pharmacies to establish correct therapy for members.</li><li>
Responsible for prescriber outreach for specific Scoreable Action Item initiatives. Work with team Pharmacist to investigate specific cases of overutilization including potential member outreach to ensure member has received products that have been dispensed under plan.</li><li>
Maintain expert knowledge in most areas of pharmacy operations. Ability to analyze and interpret various types of complex claim data under member plans. Work with pharmacies to verify claims information and reverse unnecessary claims.</li><li>
Identify opportunities for improvement in departmental and pharmacy operations with recommendations for modes of resolution.</li><li>
Train, coach, and mentor new Clinical Support Technician Staff.</li></ul>
Work from Home: Monday - Friday
Schedule: Monday - Friday, 8:00a - 5:00p local time 
Required Qualifications<ul><li>
4 or more years&rsquo; relevant experience</li><li>
Valid Pharmacy Technician Certification (PTCB or ExCPT)</li><li>
Working knowledge of Microsoft Outlook and Teams</li><li>
Ability to interpret Pharmacy Claims data</li><li>
Proficiency in computerized pharmacy systems and software applications</li><li>
Previous provider/pharmacy outreach experience</li><li>
Ability to perform duties with minimal supervision</li><li>
Proficient knowledge of Brand/Generic drug names</li></ul> 
Preferred Qualifications<ul><li>
Managed Care experience</li><li>
Advanced knowledge of Microsoft Office applications</li><li>
Understanding of medical and pharmacy terminology</li></ul>
Education<ul><li>
High School Diploma or equivalent</li></ul>
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$18.50 - $38.82
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 04/30/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Clinical Pharmacy Support Technician

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