Position Summary:

The Pharmacist/Clinician is an operation-based role that conducts criteria based & clinical review of medical data collected to perform prior authorization as per policy and procedure. The Pharmacist/Clinician will apply clinical knowledge to plan approved criteria for reviews of cases. This role will work from CVS Caremark supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Authorization team and member services department, as well as provide on-call after hours availability for urgent Prior Authorization request as needed.

Responsibilities:

Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols.

One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes. (60%)

Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements. Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations. (25%)

Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Commercial Specialty line of business. Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed. (5%)

This is a remote role open to qualified candidates within the United States.

Education:

Required: BS Pharmacy

Preferred: Doctorate - Pharm D

Active, unrestricted pharmacist license required within state of practice/residence

Prior Work Experience:

Required: 1 to 3 years

Preferred: 3 to 5 years

Required Skills & Other Minimum Required Qualifications:

• Licensed Registered Pharmacist

• Current pharmacist experience within Caremark Commercial Specialty required

• Ability and willingness to work a flexible hourly schedule to include overtime, weekends, and holidays as needed

• Knowledge of Microsoft Office Suite: Excel and Word required; Access, Outlook, PowerPoint, Visio preferable.  Keyboard skills essential.

• Must be able to multitask and utilize multiple system applications simultaneously.

• Must be able to utilize available resources independently and provide high quality work.

• Must demonstrate problem solving ability and attention to detail.

• Ability to adapt and change with workflow and shifting priorities.

• Ability to work effectively in a team environment and provide mentorship to non-clinical staff on the prior authorization team.

• Must possess excellent written, verbal, grammar, and listening communication skills.

• Must be able to effectively communicate with a diverse customer base (internal and external) in a friendly and confident manner.

• Ability to maintain confidentiality of PHI (Protected Healthcare Information).

Essential Functions:

Regular and predictable attendance

Colleague will be required to work mandatory overtime/extended work week when needed to support business needs

Colleague will be required to travel when needed

Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers.

Adhere to all policies and procedures

Attend ongoing training and development meetings

Physical Requirements:

Sits at desk for long periods of time (up to 100%)

Talking on phone for extended periods of time (up to 100%)

Computer use for extended periods of time (100%)

Reading a computer screen (up to 100%)

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Additional details about available benefits are provided during the application process and on .