Job Description
About the job Remote Coverage Review Pharmacist
Remote Coverage Review Pharmacist needs 3 years and Doctor of Pharmacy (PharmD) Degree
- Coverage Review Pharmacist requires:
- Clinical experience required, and/or completion of 1 year residency and/or board certification
- Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability. Competency in compendia navigation and research Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)
- Must be a team player, be organized and have the ability to handle multiple projects Excellent oral and communication skills Strong interpersonal and organizational skills
- Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required
- Knowledge of medical and pharmacy products License Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy
- Coverage Review Pharmacist duties:
- Responsible for various activities associated with coverage reviews and appeals including the review of medication related prior authorizations, pharmacy appeals, and member grievances focused on medications.
- Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations
- Responds to prescriber, pharmacy provider, member appeals, grievances and complaints related to the provision of pharmaceutical services within established time periods
- Builds and maintains decision trees in the prior authorization system
- Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance
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