Pharm D. required with at least two years’ experience as a pharmacist in Managed care environment
MUST HAVE MANAGED CARE experience and Medicare/Medicaid knowledge
Minimum 2 years’ recent experience reviewing and processing prior authorizations
Requirements:
Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria
Collaborates with the technicians and prior authorization team members to process referrals
Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs
Performs other related projects and duties as assigned
Job description
Location: Remote Duration: 6+ months contract Shift: Monday-Friday 9:30am-6pm local time zone
Job Description:
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 supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Auth team and member services department, as well as provide on-call after hours availability for urgent PA 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 Case Review Unit (CRU) line of business. (10%)
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%)
Experience:
Position requires proficiency with computer skills which include multitasking, navigating multiple systems, and keyboarding. Experience using MS Office, other Windows based computer applications, web based processing and telephony programs.
Minimum 2 years’ recent experience reviewing and processing prior authorizations against health plan criteria for a determination in a specialty/skilled clinical setting i.e., specialty medical office or Pharmacy Benefits Manager (PBM)
Skills:
MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
MUST HAVE 6 months of experienced with Prior Authorization(required).
MUST HAVE experience with Medicare Part D
Must Have Pharmacy Benefit Management (PBM) experience.
Education:
Pharm D. required with at least two years’ experience as a pharmacist in Managed care environment.
Must have an active license in the state of residence in good standing.
Questionnaire:
How many years of prior-authorization experience do you have?
Haw many Prior Auth cases have you handled in your last role?
Do you have experience in handling calls regarding prior authorization and appeals?
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
