Coverage Review Pharmacist

BlueCross BlueShield of Tennessee  (BCBST) is expanding its clinical operations team and seeking to hire a Coverage Review Pharmacist to help ensure accurate, compliant, and evidence‑based coverage decisions.

In this role, you will leverage your clinical expertise to perform prospective and retrospective coverage reviews, including prior authorizations and appeals, for both self‑administered and provider‑administered medications. You will apply evidence‑based clinical criteria along with state and federal regulatory requirements to ensure accurate, well‑supported coverage determinations and denial rationales.

As a key clinical resource, you’ll collaborate within a knowledgeable and highly organized team environment while working independently to apply sound clinical judgment. The ideal candidate brings a strong background in prior authorization decisioning and coverage reviews, with prior experience using NovoLogix or MHK systems is highly preferred. A solid understanding of regulatory and accreditation guidelines—including FDA, NCQA, EQRO, and CMS requirements—is required. This role is well suited for a pharmacist who values autonomous work, clinical rigor, regulatory compliance, and the opportunity to make a meaningful impact on patient access to care.

Note:

•        Must be available for weekend on call shifts that occur every few weeks.

•        Although we are based in Chattanooga, TN, this is a fully remote role.

•        Sponsorship is not available for this position.

•        At BCBST, we foster a culture where innovation is encouraged, including the responsible use of AI-enabled tools to support everyday work. As roles become more advanced, employees are expected to leverage AI, guided by established workflows, templates, and policies, to improve how we serve our members.

Job Duties & Responsibilities

• Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations. 
• Serves as a clinical resource to aid in solving basic to mid-level reviews with limited assistance and supervision.
• Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance and guidance.
• Participates in alternating team on-call rotation.
   

Job Qualifications

Education

• Doctor of Pharmacy (PharmD) Degree

Experience

• 3 years - Clinical experience required, and/or completion of 1 year residency and/or board certification

Skills\Certifications

• Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
• Competency in compendia navigation and research
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Must be a team player, be organized and able to to handle multiple projects
• Excellent oral and written communication skills
• Strong interpersonal and organizational skills
• Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required
• Knowledge of medical and pharmacy products

License

• Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy within 120 days of employment

Number of Openings Available

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Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.