Remote Coverage Review Pharmacist
New
United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 3 years
- Required Skills
- Microsoft Office
Requirements
- Doctor of Pharmacy (PharmD) Degree
- 3 years of experience
- Clinical experience, 1 year residency, or board certification
- Competency in compendia navigation and research
- Proficiency in Microsoft Office (Outlook, Word, Excel, Powerpoint)
- Ability to work independently and in a team
- Understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS)
- Knowledge of medical and pharmacy products
- Licensed or eligible for licensure in Tennessee
Responsibilities
- Review medication related prior authorizations, pharmacy appeals, and member grievances
- Perform prospective and retrospective coverage reviews and appeals per State and Federal regulations
- Respond to prescriber, pharmacy provider, member appeals, grievances and complaints related to pharmaceutical services
- Build and maintain decision trees in the prior authorization system
- Maintain denial rationale associated with clinical criteria
- Ensure decision letters meet regulatory compliance
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