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Pharmacist - Clinical Pharmacist Advisor Medicare

US Tech Solutions

Role overview

Qualifications

  • Pharm D. required
  • Minimum 2 years’ recent experience in specialty/skilled clinical setting
  • Managed care experience
  • Active pharmacy license in good standing

Responsibilities

  • Evaluate and review all prior authorization requests and render coverage determinations
  • Collaborate with technicians and prior authorization team members to process referrals
  • Maintain professional and technical knowledge of drug and disease states
  • Perform other related projects and duties as assigned

Key facts

Hard skills

Managed Care Prior Authorization Medicare Part D Pharmacy Benefit Management

Other skills

  • Communication
  • Multitasking
  • Technical Acumen

About the company

US Tech Solutions logo

US Tech Solutions

Staffing & Recruiting

USTECH SOLUTIONS is the largest privately owned diversity workforce partner with a global footprint. For 20+ years, we have partnered with leading MSPs and some of the world’s largest enterprises to deliver a flexible workforce. We serve Fortune 500 giants and growing businesses alike, reinventing the role of humans in a digital workforce. ‘Reinventing Human’ is about connecting you with top talent and seamlessly integrating new hires into your programs through our next gen AI powered Talent platforms. As the largest private diversity supplier in the US, we champion inclusion and unlock hidden potential. We work with leading MSPs and are a trusted strategic partner to the world’s top brands. At USTECH SOLUTIONS, we're inverting the talent hiring pyramid by offering a range of solutions from curated talent pools, workforce management services, and IT services resourcing to IC compliance. Our legacy and close affinity to the computing industry has equipped us with the expertise and vision to provision AI platform solutions that help organizations to innovate faster. Considering Statement of Work? Meet US Tech Digital (ustechdigital.com). We're helping businesses achieve digital leadership through our tailored SOW solutions, utilizing market-leading technology products and our proprietary in-house developed platform solutions. Explore our full range of services and solutions by visiting our website: ustechsolutions.com

Company details

Company typeLarge
IndustryStaffing & Recruiting
Company size1001 - 5000

Links

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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.
 

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Marcus Rivera

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