nirvanaHealth | RxAdvance · 22 hours ago
Clinical Advisor
Southborough, MA
Full-time
Onsite
Mid, Senior Level
$100K/yr - $140K/yrnirvanaHealth, under RxAdvance Corp., is committed to transforming healthcare through innovative solutions. The Clinical Advisor will utilize pharmacy expertise and healthcare payer knowledge to support prior authorization operations and collaborate with pharmacy technicians and pharmacists in Pharmacy Operations.
Health CareInformation TechnologyMedicalPharmaceuticalSoftware
Hiring Manager
Shamaila Khan, PHR
Responsibilities
Serves as a subject matter expert in the development and maintenance of drug formularies and clinical programs
Works with stakeholders to understand client’s product-specific requirements and configuration needs and translate them into technical design specifications and data flow for development, coding, and configuration
Coordinates activities as part of the Formulary Development and Maintenance team and recommends measures to improve performance and efficiency
Manage operations of the Pharmacy & Therapeutics (P&T) Committee including scheduling drug class reviews, reviewing new branded agents, coordinating internal/external membership, documenting P&T minutes, and preparing and organizing P&T files
Conducts and evaluates research necessary for the development of utilization management strategies
Performs clinical reviews of PA, Step Therapy, Quantity Limit, and all other pharmacy utilization requests in accordance with quality, timeliness, and efficiency standards
Performs coverage determinations and appeals requests according to criteria guidelines and in compliance with all state and federal regulations, including Medicare and Medicaid
Takes calls from internal and external stakeholders as it pertains to the PA process, answering in a timely, accurate and professional manner
Develops and implements clinical utilization criteria for new market entries and market updates utilizing evidence-based medicine principles
Makes strategic recommendations including benefit design and formulary analysis, provision of clinical drug information, Pharmacy & Therapeutics support and participation, rational drug formulary positioning, online system edits and restrictions, ongoing clinical product evaluations, and client pharmacy benefit utilization and performance trends as required
Assists with compiling statistical data, reporting and analyses to demonstrate PA clinical, financial, and operational effectiveness and quality
Supports Fraud, Waste and Abuse (FWA) program system oversight and communicates any suspected fraud discovered
Qualification
Required
Bachelor's degree in pharmacy or related fields
Expert knowledge of the principles and practices of pharmaceutical science
Working knowledge of managed care and policy development
Working knowledge of state and federal controlled substances and related laws, rules, and regulations
Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology
Registered and in good standing with the Board of Registration in Pharmacy
Active, non-restricted pharmacist license
Preferred
Doctor of Pharmacy (PharmD) degree from an ACPE accredited college
Managed Care or Clinical Residency program residency
Company
nirvanaHealth | RxAdvance
nirvanaHealth is an innovative Payer and pharmacy benefit manager (PBM) platform provider that leverages their robotic process automation (RPA) cloud platforms to manage integrated medical, pharmacy and behavioral services that reduce overall administrative and medical costs and improve quality.
Founded in 2013
51-200 employees
H1B Sponsorship
nirvanaHealth | RxAdvance has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (24)
2024 (24)
2023 (30)
2022 (39)
2021 (26)
2020 (30)
Funding
Current Stage
Growth StageTotal Funding
$110MKey Investors
CenteneGeorge M. Rapier III
2022-03-22Series Unknown· $60M
2018-09-21Series Unknown· $50M
2018-03-13Corporate Round
Leadership Team
Ravi Ika
President & CEO
Recent News
Company data provided by crunchbase