Fully remote (never coming onsite)
Position Summary
This position is responsible for resolving coverage determination/redetermination reviews in a timely manner. There may be some interaction with the health care professionals in the provision and coordination of customer care. Must be comfortable communicating by telephone or fax, with patients and physicians for patient care.
Complete Clinical Reviews and provide a determination of Medicare-Medicaid Coverage Determination/Redetermination, Medical Review, Global Exception et cetera, by following established clinical process. Continually monitor the quality and efficiency of the Prior Authorization process including coverage criteria, denial language, and communication with prescribers and members. Provide recommendations to physicians to improve medication regimens as appropriate.
Duties
This individual must have excellent interpersonal skills. Will be responsible for: Complete Clinical Reviews and provide a determination of Medicare-Medicaid Coverage Determination/Redetermination, Global Exception etc. by reviewing all requests which are not clearly approvable based on specified criteria. Continually monitor the quality and efficiency of the Prior Authorization process including coverage criteria, denial language, and communication with prescribers and members. Provide recommendations to physicians to improve medication regimens as appropriate. Assist in process improvement and work with other members of the coverage determination pharmacy team to ensure quality of reviews.
1. Complete Clinical Reviews and provide a determination of Medicare-Medicaid Coverage Determination/Redetermination, Global Exception etc. by reviewing all requests which are not clearly approvable based on specified criteria (algorithms).
2. Continually monitor the quality and efficiency of the Prior Authorization process including coverage criteria, denial language, and communication with prescribers and members. Provide recommendations to physicians to improve medication regimens as appropriate.
3. Complete all annual NCQA, client required training requirements.
4. Assists Member Services and other internal customers in responding to and resolving pharmacy-related inquiries from members (NCQA Requirement).
5. Maintain open lines of communication with other functional areas/departments.
6. Responsible for staying current with clinical literature and guidelines and relaying those to the program development core teams.
Experience
BACKGROUND/EXPERIENCE (Required)
Proficiency in Microsoft Excel, Word, Outlook, and SharePoint
Superior written and verbal communication skills
Will considered a recent grad with an active license
BACKGROUND/EXPERIENCE (Preferred)
Managed care experience (Medicaid/Medicare)
1+ year of previous clinical pharmacy experience required
2+ years of experience working as a pharmacist (managed care experience is highly desirable, but not required)
Knowledge of clinical program components, formulary designs, and prescription benefit trends preferred
Board certification and managed care residency preferred
Experience
Previous pharmacy experience in clinical settings preferred. Appropriate state license required. Experience in prior authorization is preferred. Basic computer skills required. Strong organizational skill, interpersonal skills, and detail orientation important for this position.
Education
Pharm D. required. Must have an active license in good standing. License should be active within the state they reside in with no history or restrictions.
Notes:
WFH 100% remote
Mon-Fri 9-5:30
