Offer summary

Qualifications:

PharmD degree and a current, active Pharmacist license in good standing., Minimum of one year of experience as a pharmacy manager, preferably with commercial and Medicare Part D appeals., Strong knowledge of medication, disease states, and medical terminology relevant to pharmacy practice., Excellent communication, organizational, and customer service skills..

Key responsabilities:

Evaluate prior authorization appeals for drug appropriateness according to policy criteria and client guidelines.

Provide customer service to health plan clients, practitioners, and members, serving as an educational resource.

Perform case reviews and present cases to the appeal decision committee for medical director sign-off as needed.

Maintain productivity and quality scores, participate in training, and recommend operational improvements.

Job description

Description

WHO WE ARE

Founded in 1983, the Medical Review Institute of America (MRIoA) is the market leader for technology-enabled utilization management and clinical medical review solutions. We have an outstanding reputation for excellence and achieve continual improvement.

At MRIoA, we believe our employees are the key to our success. Here, you are more than just a cog in the machine – you are a valued member of our team.

WE OFFER

A competitive compensation package.
Benefits include healthcare, vision and dental insurance, a generous 401k match, paid vacation, personal time, and holidays.
Growth and training opportunities.
A team atmosphere with fun events and prizes scheduled throughout the year.

POSITION OVERVIEW

Roles:

To evaluate prior authorization appeals for drug appropriateness per policy criteria and client guidelines
To provide excellent customer service to health plan clients, practitioners and members
To serve as an educational resource regarding drug and clinical information for all internal and external customers

Major Responsibilities or Assigned Duties:

Perform case reviews for prior authorization appeals
Present cases to appeal decision committee as needed for medical director sign off
Maintain monthly and annual productivity score per company standard
Maintain monthly and annual quality score per company standard
Train across all queues and lines of business as requested by MRIoA leadership
Complete all client specific training as requested by MRIoA leadership
Maintain up-to-date records of case completion
Consistently show willingness to take cases and project assignments as requested
Demonstrate respect in interactions across the company
Provide ideas for promotion and growth of the company as requested
Communicate with team and supervisor as appropriate to proactively inform of issues or concerns
Recognize and recommend operational improvements
Actively participate in the MRIoA evaluation process (both company and individual)
Participate in all company meetings and committees as requested
Maintain appropriate state pharmacist license in good standing with completion of required CEs
Complete other duties as requested or approved by the Supervisor, Appeals Pharmacists or Senior Director of Operations

Requirements

Skills and Experience:

Minimum of one year of experience working as a pharmacy manager preferred
Experience working with commercial and Medicare Part D appeals strongly preferred
Experience working for a health plan or pharmacy benefits manager preferred
Ability to work in a fast-paced and high-functioning environment and meet deadlines while managing multiple high priorities
High level of medication and disease state knowledge, basic anatomy, physiology and medical terminology within the scope of pharmacy practice
Credentialed and privileged by the company's credentialing committee
Strong working knowledge of medical insurance terminology and processes
Personal computer literacy and high competency in use of Microsoft Word, Excel, OneNote, PowerPoint, etc.
Strong organizational skills & critical thinking capabilities with attention to detail
Strong oral and written communication skills
Well-developed customer service and training skills
Willingness to obtain additional state licensure as required for the position

Education:

PharmD degree
Current, active Pharmacist license in good standing

Work Environment:

Ability to sit at a desk, utilize a computer, telephone, and other basic office equipment is required. This role is designed to be a remote position (work-from-home).

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

This company is a drug-free workplace. All candidates are required to pass a Background Screen before beginning employment. All newly hired employees will take a Drug Screen, as well as agreeing to all necessary Compliance Regulations on their first day of employment.

Required profile