Clinical Pharmacist 1

Pharmacy Appeals Department – Dept 247

Location: 100% Remote - National SHIFT: 9am – 6pm EST Duration: 3 months

Job Profile Summary

Evaluate redetermination and appeals coverage requests. Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician's recommended denial, suggested formulary alternatives, comments and attachments for appropriateness. Verifies member's ID number and date of birth. Verifies member's eligibility in the appropriate health plan eligibility system. Records carrier and group number if applicable. Checks for previous prior authorization decisions. Verifies coverage in member's prescription benefit when necessary. Verifies coverage in member's health plan benefit when necessary. Evaluates prescription claim history. Reviews chart notes and/or lab values. Identifies provider specialty when appropriate. Applies Medical Policy Criteria to prior authorization requests. Evaluates whether request meets criteria for approval. Reviews the request using professional clinical judgment on a case by case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested. Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool. Communicates with physicians regarding prior authorization: For a non-formulary drug Plan benefits, exclusions Quantity limits Age restrictions Formulary alternatives Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department) Compiles data for reporting purposes: Drug utilization of non-formulary drugs Overturned IPS recommended denials Audit pharmacy claims greater than $200.00 Suggest addition or deletion of drugs to/from the formulary Updating qty/days or age limit ends Support National P&T Committee Other tasks which may arise during the performance of any of the above mentioned duties

Candidate Requirements

Education/Certification - Required: Pharm D. - Preferred: n/a

Licensure - Required: Any US state - Preferred: n/a

Years of experience requiredDisqualifiersBest vs. averagePerformance indicators - Ideal candidates are: Self-motivated Metric driven (retail experience can be an indicator of this but not always)---what are the metric goals in their current role? How many cases per day do they complete?---this is crucial information if they are working in a prior auth role or have worked prior auth before Easily adaptable to frequent change Any previous client experience or experience with our systems (MHK, Client, Micromedex, AHFS to name a few) Minimal gaps in employment history Licensure in the following states COULD be a plus – NC, IN, WA, NH, GA Must haves: At least one year of professional RPh experience Nice to haves: Some experience working in managed care, understanding of Medicare/Medicaid law Disqualifiers: n/a Performance indicators: Sign 85 – 100 cases daily