Clinical Pharmacist

Summary:

• Work Mode: 100% Remote
• SHIFT: 9am – 6pm EST, NO OT
• Duration: 3 months

Responsibilities:

• Review completed prior authorization requests from providers.
• Verify member's ID number, date of birth, and eligibility in the health plan system.
• Record carrier and group numbers if applicable.
• Check previous prior authorization decisions and verify prescription and health plan benefits.
• Evaluate prescription claim history and review chart notes/lab values.
• Identify provider specialty when appropriate.
• Apply Medical Policy Criteria to prior authorization requests.
• Evaluate requests for approval using professional clinical judgment.
• Research and contribute drug references and clinical information for prior authorization review.
• Communicate with physicians regarding non-formulary drugs, plan benefits, exclusions, quantity limits, age restrictions, and formulary alternatives.
• Retrieve and collect data through available reporting resources.
• Compile data for reporting purposes, including drug utilization and audit pharmacy claims.

Requirements:

• Pharm D. required.
• At least one year of professional RPh experience.
• Any US state licensure.

Preferred Skills:

• Some experience working in managed care.
• Understanding of Medicare/Medicaid law.