Job Description
- Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design.
- Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols.
- One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes. (60%)
- Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements.
- Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations. (25%)
- Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Specialty line of business.(10%)
- Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed.(5%).
Job Responsibilities
- The Pharmacist/Clinician is an operation-based role that conducts criteria based & clinical review of medical data collected to perform prior authorization as per policy and procedure.
- The Pharmacist/Clinician will apply clinical knowledge to plan approved criteria for reviews of cases.
- This role will work from CVS Caremark supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Auth team and member services department, as well as provide on call after hours availability for urgent PA request as needed..
Numbers & Facts
| Location | (Remote) |
| Job Type | Full-time |
| Salary | $52–$55 Per Hour |
| Year Founded | null |
| Website | https://sgsconsulting.com/ |
Qualifications
Required: Bachelor's Degree - BS Pharmacy and an active pharmacist license in the state of practice/residence.
Preferred: Doctorate - Pharm D
Skills
- prior authorization
- PBM
Skills
- Clinical Assessmentunmatched
- Clinical Dataunmatched
- Clinical Validationunmatched
- Consultingunmatched
- Diseaseunmatched
- Health Planunmatched
- Healthcareunmatched
- Healthcare Providersunmatched
- On Callunmatched
- Patient Care Authorizationsunmatched
- Patient Care Denialsunmatched
- Pharmacyunmatched
- Service Level Agreement (SLA)unmatched
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