Clinical Prior Authorization Pharmacist
Position Summary
As a Clinical Pharmacist Medicare, you will directly support Medicare Part D members and providers with requests related to their pharmacy benefits. You will be responsible for:
- Ensuring cases are accurately set up for our members.
- Reviewing clinical information for decisioning the request.
- Performing outreach to providers for more information when needed.
- Ensuring accurate decisions that comply with compendia and Medicare guidance and timelines.
This is a great opportunity to initiate a career with a leading healthcare company by reviewing information and completing timely and accurate documentation of all Medicare Part D requests, in compliance with Medicare guidelines, while promoting a best-in-class service experience.
Duties
The role involves:
- Ensuring the accuracy of case setup and clinical review of Medicare appeals cases by thoroughly reviewing internal notes or fax requests for pertinent information.
- Providing clear and concise documentation.
- Contacting providers when necessary to obtain clinical details for case decisions.
- Adhering to work instructions and Medicare guidelines to ensure proper case processing.
- Complying with mandated timelines, as well as departmental productivity and quality standards.
- Applying clinical judgment and knowledge effectively, utilizing drug compendia resources, evolving work instructions, and Medicare guidance.
- Participating in development discussions and receiving feedback from the direct supervisor to support continuous improvement.
Experience
- Previous experience in a Managed Care/PBM environment (preferred).
Education
- Bachelor's degree in pharmacy or Pharm D. required.
- Must have an active license in good standing in the state of residence.
- Training M-F from 9am-5:30pm EST.
Location: Remote - USA
Skills required for this job:
- Clinical review
- Documentation
- Healthcare prescription review
- Medicare
- Medicare Appeals
- Prior authorization