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Pharmacist - Prior Authorization - Remote ID-5560

Duties Description 

Performs clinical review of prior authorization requests. Utilizes clinical experience and skills in a collaborative process to apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render appropriate coverage determination. Monitors prescribing habits of participating physicians. Makes recommendations to physicians to improve medication regimens as appropriate.

- Improves quality of service to members by developing programs to provide optimal pharmacy care to patients, participating in dispute resolution of drug utilization review, measuring and documenting improvements in patient care, and/or improving claim adjudication for proper provider reimbursement.

- Acts as "subject matter expert" for clinical pharmacy issues (i.e., appeal, fraud, cognitive services, drug reviews, and education). Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Educates providers and staff regarding the appropriate use of pharmaceutical treatment regimens. May develop and maintain training documents for staff development.

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- Performs other duties as required

 

  • This is a WFH position for candidates with a strong clinical/technical knowledge base and independent problem-solving skills. Pharmacist can have an RPh or Pharm.D degree
  • Must have active license in state you reside in!
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