Job Duties & Responsibilities
- Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations.
- Serves as a clinical resource to aid in solving basic to mid-level reviews with limited assistance and supervision.
- Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance and guidance.
- Participates in alternating team on-call rotation.
Job Qualifications
Education
- Doctor of Pharmacy (PharmD) Degree
Experience
- 3 years - Clinical experience required, and/or completion of 1 year residency and/or board certification
Skills\Certifications
- 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 able to to handle multiple projects
- Excellent oral and written 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 within 120 days of employment
Number of Openings Available
1
Worker Type:
Employee
Company:
BCBST BlueCross BlueShield of Tennessee, Inc.
