Position Title: Clinical Pharmacist 1
Location: Remote
Duration: 3 Months
Schedule: 9am 6pm EST, No OT
PR: $60-65.00/HR
Key Responsibilities
- Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician's recommended denial, suggested formulary alternatives, comments, and attachments for appropriateness.
- Verifies member's ID number and date of birth.
- Verifies member's eligibility in the appropriate health plan eligibility system.
- Records carrier and group number if applicable.
- Checks for previous prior authorization decisions.
- Verifies coverage in member's prescription benefit when necessary.
- Verifies coverage in member's health plan benefit when necessary.
- Evaluates prescription claim history.
- Reviews chart notes and/or lab values.
- Identifies provider specialty when appropriate.
- Applies Medical Policy Criteria to prior authorization requests.
- Evaluates whether request meets criteria for approval.
- Reviews the request using professional clinical judgment on a case-by-case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.
- Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool
Communicates with physicians regarding prior authorization:
- For a non-formulary drug
- Plan benefits, exclusions
- Quantity limits
- Age restrictions
- Formulary alternatives
- Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department)
Education Required: Pharm D.
License Required: Any US state
Licensure in the following states COULD be a plus NC, IN, WA, NH, GA
Must haves: At least one year of professional RPh experience
Nice to haves: Some experience working in managed care, understanding of Medicare/Medicaid law
Performance indicators: Sign 85 100 cases daily