Clinical Pharmacist

Summary:

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

Responsibilities:

• Review completed prior authorization requests from providers and pharmacy technician recommendations.
• Verify member’s ID number, date of birth, and eligibility in health plan systems.
• Record carrier and group numbers if applicable.
• Check for previous prior authorization decisions.
• Verify coverage in member’s prescription and health plan benefits as necessary.
• Evaluate prescription claim history and review chart notes or lab values.
• Identify provider specialty when appropriate.
• Apply Medical Policy Criteria to prior authorization requests.
• Evaluate whether requests meet criteria for approval using professional clinical judgment.
• Research and contribute drug references and clinical information to facilitate prior authorization review.
• Communicate with physicians regarding prior authorization for 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 of non-formulary drugs and audit pharmacy claims greater than $200.00.

Requirements:

• Education: Required Pharm D.
• Licensure: Required in any US state.
• Must have at least one year of professional RPh experience.
• Top 3 must-have hard skills:
  • Self-Motivated/Good Time Management Skills
  • Working Knowledge of Office Suite
  • Goal Oriented

Preferred Skills:

• Some experience working in managed care.
• Understanding of Medicare/Medicaid law.