We are looking for licensed Pharmacists to join one our our renowned clients in the Health Insurance Industry. If you have the credentials, and able to work remotely, this opportunity is for you!
Primary Responsibilities:
• Manage outbound calls to providers.
• Provide support for both Medicare and Retirement via phone and chat.
• Reviewing clinical information submitted by providers to determine whether a medication meets plan-specific coverage criteria.
• Evaluating factors such as diagnosis, previous therapies, treatment history, quantity requested, dosing, and clinical
appropriateness.
• Approving requests when criteria are met.
• Issuing clinical denials when criteria are not met and plan regulations allow pharmacist-level decisioning.
• Referring cases to a Medical Director when regulatory or client requirements mandate physician review before a denial can be
issued.
• Documenting clinical rationale and ensuring all decisions comply with client, state, federal, CMS, and accreditation
requirements.
Required Qualifications:
• Valid Pharmacist license
• 1+ years of experience in a related environment (i.e. office, administrative, clerical, customer service, etc.) using phones and
computers as the primary job tools
• Advanced Microsoft and Windows PC applications skills, which includes the ability to navigate and learn new and complex
computer system applications
• Available to work (40 hours/week) Monday- Friday. Flexible to work any of our 8 hour shift schedules during our normal
business hours of (8:00am to 7:00pm ATL)
• Bilingual Spanish/English proficiency