Clinical Pharmacist 1

Pharmacy Reviewer

Location: 100% Remote (USA Only) SHIFT: Mon - Fri 9am – 6pm EST, No OT Duration: 3 months, potential to extend or convert

Typical Day in the Role:

• 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 required Disqualifiers: n/a

Performance indicators:

• Sign 85 – 100 cases daily

Top 3 Must-Have Hard Skills

1. Self-Motivated/Good Time Management Skills

2. Working Knowledge of Office Suite

3. Goal Oriented