SummaryGainwell Technologies is seeking a
Medical Reviewer (Pharmacist) to provide pharmacy and clinical expertise supporting Medical Review Services for California healthcare programs. This role supports pharmacy review, claim adjudication, drug rebate activities, drug utilization review, Treatment Authorization Requests (TARs), and other Medical Review Services functions.
Your role in our mission- Perform pharmacy and medication-related clinical reviews.
- Support pharmacy claim review and adjudication activities.
- Provide clinical expertise for drug utilization review and drug-related authorization requests.
- Support drug rebate and pharmacy program activities as assigned.
- Review pharmacy documentation for compliance with applicable policies and coverage requirements.
- Provide technical expertise and assistance related to pharmacy review.
- Document findings and recommendations accurately and timely.
- Collaborate with physicians, nurses, pharmacy teams, operations, and other healthcare professionals.
- Maintain knowledge of applicable pharmacy policies and regulatory requirements.
What we're looking for- Current, non-expired pharmacist license from the State of California, in good standing.
- Must not be under suspension from Medicare, Medicaid, or pharmacy practice in California.
- Must not have been previously sanctioned for fraud or abuse.
- Three (3) years of previous experience as a pharmacy consultant for a government or private-sector healthcare payer; or one (1) year of MMIS experience in a large state providing technical expertise and assistance for pharmacy review.
- Strong oral and written communication skills.
- Strong knowledge of pharmacy practices, medication review, and healthcare reimbursement processes.
What you should expect in this role- Full-time position.
- Remote work environment.
- Monday through Friday work schedule.
- Work primarily from your home office while supporting Medical Review Services for California healthcare programs.
- Spend the majority of your day reviewing pharmacy, clinical, claim, authorization, and supporting documentation.
- Work independently while collaborating with physicians, pharmacists, nurses, other clinical specialists, operations teams, and business partners.
- Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
- Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status.
- Maintain knowledge of applicable medical and pharmacy policies, coverage requirements, clinical standards, and regulatory guidelines.
- Meet established quality, accuracy, productivity, and turnaround-time expectations.
- Receive ongoing training and support related to program requirements, systems, policies, and medical review processes.
- Travel requirement: 0-10%.
This position is being posted for pipeline purposes, and we welcome applications on an ongoing basis.#LI-REMOTE
#LI-MA1
The pay range for this position is $100,000 - $140,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You'll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
