Job ID: 26-118614
Position Type: Remote
Location: Remote
Work Type: Fulltime
Est. Pay Range: $53.00/hr. to $58.00/hr. all-inclusive on W2
Position Summary:
- 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.
Duties:
- 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 Specialty 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:
- 2+ years of Prior Authorization review experience
- PBM, Managed Care, or Health Plan experience strongly preferred
- Specialty Pharmacy experience is a plus
- Comfortable with high-volume inbound and outbound provider interaction
- Previous pharmacy experience in PBM preferred.
- Appropriate state license required.
- Basic computer skills required.
- Strong organizational skill, interpersonal skills, and detail orientation important for this position.
- Able to manage approximately 40 prior authorization cases per day
- Proven remote work experience
- Strong communication and documentation skills
- Available for the full training period
- Comfortable working one weekend day each week
Education:
- Required: Bachelor's Degree - BS Pharmacy and an active pharmacist license in the state of practice/residence.
- Preferred: Doctorate - Pharm D
Employee Benefits:
At LanceSoft, full time regular employees who work a minimum of 30 hours a week or more are entitled to the following benefits:
Four options of medical Insurance
Dental and Vision Insurance
401k Contributions
Critical Illness Insurance
Voluntary Permanent Life Insurance
Accident Insurance
Other Employee Perks
LanceSoft is a certified Minority Business Enterprise (MBE) and an equal opportunity employer. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. LanceSoft makes hiring decisions based solely on qualifications, merit, and business needs at the time.
