Clinical Pharmacy Reviewer (Pharmacist)
New
D
Dane StreetPharmacy benefits
United StatesContractMiddle
Salary not disclosed
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Job Details
- Experience
- Minimum of 3 years of Prior Authorization and/or Appeals review experience within a PBM environment.
Requirements
- Hold a Doctor of Pharmacy (PharmD) degree from an accredited university.
- Maintain an active, unencumbered pharmacist license in any U.S. state.
- Have a minimum of 3 years of prior authorization and/or appeals review experience within a PBM environment.
- Provide and support your own internet service for remote work.
- Maintain an uninterrupted internet connection.
- Preferred: Experience with Medicare Part D and Medicaid pharmacy benefits.
- Preferred: Knowledge of commercial insurance pharmacy benefits and formulary management strategies.
- Preferred: Knowledge of step therapy requirements, quantity limit programs, and specialty medications.
- Preferred: In-depth knowledge of Drug Utilization Review (DUR).
- Preferred: Demonstrated ability to interpret and apply complex clinical guidelines.
Responsibilities
- Evaluate complex prior authorization requests.
- Review appeals and medication coverage determinations.
- Assess clinical appropriateness and compliance with evidence-based guidelines.
- Interpret complex drug criteria and formulary guidelines.
- Apply step therapy requirements and quantity limits for specialty and non-specialty medications.
- Conduct Drug Utilization Reviews (DUR).
- Make objective decisions and uphold medical necessity standards.
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