Job Description
About the Company
Launched in 2018, OI Infusion aims to improve the patient and provider experience while simultaneously lowering costs for both providers and payers. The company operates both an infusion management service organization (MSO) and a network of multi-site ambulatory specialty infusion centers, called Novella. The MSO business line offers services such as staffing, managing operations, and revenue cycle operations for physician practices, enabling the specialty groups to provide infusion services to their patient base. We help our partners treat their patients in a comfortable, convenient, and affordable setting. The Novella ambulatory specialty infusion centers allow business to contract directly with payers and are a major lever for future growth. Since its inception, Novella has scaled to operate over 35 clinics in the New England region.
Position Summary
The Clinical Review Pharmacist is the quality gate that ensures every infusion order is clinically appropriate, payer-compliant, and accurately documented before authorization is requested. This role goes beyond medical necessity review: it requires payer policy literacy, sharp attention to detail, proactive case-building for complex and off-label therapies, and hands-on ownership of the denial response process from root-cause analysis through appeal or peer-to-peer support.
The right candidate does not simply check boxes against a policy database. They read the full clinical picture, anticipate payer pushback before submission, communicate clearly and specifically with sites and navigators about what is needed and why, and — when a denial occurs — build an airtight case to overturn it rather than placing the burden entirely on the referring provider
Salary: $100k-$130k.
Locatio: Remote
Essential Duties and Responsibilities
- Conduct thorough medical necessity review of infusion orders for both commercial and government payers across all designated drug therapies, applying the correct payer-specific medical policy for each case
- Review the full patient chart to determine whether the patient meets payer criteria, including diagnosis, step therapy requirements, lab values, dosing, and continuation-of-therapy documentation
- Maintain and actively use the PGR policy database as the primary source of truth; flag and update policy changes on a quarterly basis in coordination with the Director of RCM
- Apply consistent, templated communication standards when PGR review results in a required action by the site, navigator, or provider.
- Review and verify that each order is correctly dosed flagging dosing discrepancies with ordering providers before moving forward
- When auth denials are received, work with intake leaders to write specifically tailored LMN to overturn the decision when necessary
- Assist the intake team reviewing auth denials with clinical guidance and how to best proceed
- Collaborate with clinical operations team on review and maintenance of order sets and drug preparation sheets to ensure clinical accuracy
- Experience in navigating a fast-paced, high-volume environment with competing priorities and evolving payer landscapes
Minimum Qualifications
- Minimum 2 years of infusion therapy experience preferred- Hospital, home health, etc.
- Proficient with Microsoft suite- Word, Excel, Outlook
- Ability to work independently and manage multiple tasks
- Bachelor of Pharmacy or a Doctor of Pharmacy preferred
- Be a pharmacist a current/clear license within the state
- Minimum of four years of infusion pharmacy experience as a pharmacist preferred
- Experience with providing clinical education and support for specialty medications
- Clinical education and support for specialty medications is a plus
- Thrives working in a fast pace working environment
Physical Demands and Work Environment
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions
While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand; walk; sit; and reach with hands and arms. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus. The noise level in the work environment is usually low to moderate.
Note
This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship.
Originally posted on Himalayas
