Biotech and Pharmaceutical, Clinical Information, Data Collection, Formulary, Health Plan, Legal, Managed Care, Medicaid, Medicare, Office Suites, Patient Care Authorizations, Pharmacy
LOCATION
Various, TX
POSTED
1 day ago
Work Mode: 100% Remote (USA Only) Duration: 3 months, potential to extend or convert SHIFT: Mon - Fri 9am – 6pm EST, No OT
Responsibilities:
Review completed prior authorization requests from providers and pharmacy technician recommendations.
Verify member's ID number, date of birth, and eligibility in the health plan system.
Record carrier and group number if applicable.
Check for previous prior authorization decisions.
Verify coverage in member's prescription and health plan benefits when necessary.
Evaluate prescription claim history and review chart notes/lab values.
Identify provider specialty when appropriate and apply Medical Policy Criteria to requests.
Evaluate requests for approval using professional clinical judgment.
Research and contribute drug references and clinical information for authorization reviews.
Communicate with physicians regarding non-formulary drugs, plan benefits, exclusions, quantity limits, age restrictions, and formulary alternatives.
Retrieve and collect data through available reporting resources.
Compile data for reporting purposes, including drug utilization and audit pharmacy claims.
Requirements:
Pharm D. degree.
Licensure in any US state.
At least one year of professional RPh experience.
Preferred Skills:
Experience working in managed care and understanding of Medicare/Medicaid law.