- Review and evaluate prior authorization requests according to clinical guidelines and benefit plans.
- Complete coverage determinations within established turnaround times with high accuracy.
- Collaborate with prescribers to recommend cost-effective therapeutic alternatives.
- Coordinate the clinical review process for pharmacy benefit appeals.
- Develop and maintain clinical criteria and utilization management programs.
- Analyze pharmacy utilization data to identify prescribing trends and cost-saving opportunities.
- Provide clinical mentorship and leadership to the pharmacy operations team.
- Ensure all activities comply with HIPAA, NCQA, URAC, and federal/state regulations.
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