Clinical Pharmacist

Summary:

• Work Mode: 100% Remote - National
• Duration: 3 months
• SHIFT: 9am – 6pm EST; No OT

Responsibilities:

• Evaluate redetermination and appeals coverage requests
• Review completed prior authorization requests from providers and pharmacy technician recommendations
• Verify member's ID number, date of birth, and eligibility in the appropriate health plan eligibility system
• 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 and/or lab values
• Identify provider specialty when appropriate
• Apply Medical Policy Criteria to prior authorization requests
• Review requests using professional clinical judgment on a case-by-case basis
• Research and contribute drug references and clinical information for prior authorization review
• Communicate with physicians regarding prior authorization for 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, such as drug utilization of non-formulary drugs, overturned IPS recommended denials, and audit pharmacy claims greater than $200.00

Requirements:

• Education: Pharm D.
• Licensure: Required in any US state
• At least one year of professional RPh experience
• Self-motivated and metric-driven
• Easily adaptable to frequent change

Preferred Skills:

• Experience in managed care and understanding of Medicare/Medicaid law
• Experience with systems such as MHK, Company, Micromedex, AHFS
• Licensure in NC, IN, WA, NH, GA could be a plus