Remote Coverage Review Pharmacist needs 3 years and Doctor of Pharmacy (PharmD) Degree
Coverage Review Pharmacist requires:
Clinical experience required, and/or completion of 1 year residency and/or board certification
Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability. Competency in compendia navigation and research Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)
Must be a team player, be organized and have the ability to handle multiple projects Excellent oral and communication skills Strong interpersonal and organizational skills
Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required
Knowledge of medical and pharmacy products License Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy
Coverage Review Pharmacist duties:
Responsible for various activities associated with coverage reviews and appeals including the review of medication related prior authorizations, pharmacy appeals, and member grievances focused on medications.
Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations
Responds to prescriber, pharmacy provider, member appeals, grievances and complaints related to the provision of pharmaceutical services within established time periods
Builds and maintains decision trees in the prior authorization system
Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance