Clinical Pharmacist

Summary:

• Work Mode: 100% Remote - National
• Shift: 9am – 6pm EST; No OT
• Duration: 3 months

Responsibilities:

• Evaluate redetermination and appeals coverage requests.
• Review completed prior authorization requests and pharmacy technician recommendations.
• Verify member’s ID number, date of birth, and eligibility in the health plan system.
• Check for previous prior authorization decisions.
• Verify coverage in member’s prescription and health plan benefits.
• Evaluate prescription claim history, chart notes, and lab values.
• Identify provider specialty when appropriate.
• Apply Medical Policy Criteria to prior authorization requests.
• Use professional clinical judgment for medication requests not covered by P&T Committee criteria.
• Research and contribute drug references and clinical information for prior authorization review.
• Communicate with physicians regarding non-formulary drugs, plan benefits, exclusions, quantity limits, age restrictions, and formulary alternatives.
• Retrieve and collect data through available reporting resources.
• Compile data for reporting purposes, including drug utilization, overturned IPS recommended denials, and pharmacy claims audits.

Requirements:

• Required Education: Pharm D.
• Licensure: Required in any US state.
• Minimum one year of professional RPh experience.

Preferred Skills:

• Self-motivated and metric-driven.
• Easily adaptable to frequent change.
• Experience with systems such as MHK, Company, Micromedex, AHFS.
• Minimal gaps in employment history.
• Licensure in states like NC, IN, WA, NH, GA is a plus.
• Experience in managed care and understanding of Medicare/Medicaid law is advantageous.