Clinical Pharmacist

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
• Department growth
• Increased volume
• 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: o For a non-formulary drug o Plan benefits, exclusions o Quantity limits o Age restrictions o Formulary alternatives.
• Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department).
• Compiles data for reporting purposes: o Drug utilization of non-formulary drugs o Overturned IPS recommended denials o Audit pharmacy claims greater than $200.00 o Suggest addition or deletion of drugs to/from the formulary o Updating qty/days or age limit ends o Support National P&T Committee o 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-motivatedMetric 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 beforeEasily adaptable to frequent changeAny previous client experience or experience with our systems (MHK, Client, Micromedex, AHFS to name a few)Minimal gaps in employment historyLicensure in the following states COULD be a plus – NC, IN, WA, NH, GAMust haves: At least one year of professional RPh experienceNice to haves: Some experience working in managed care, understanding of Medicare/Medicaid lawDisqualifiers: n/aPerformance indicators: • Sign 85 – 100 cases daily