Clinical Pharmacist – Prior Authorization

Clinical Pharmacist – Prior Authorization

Requirements

• 2 years’ experience working as a pharmacist in a PBM setting.
• Current experience working with commercial Prior Authorizations in PBM
• Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology
• Ability to prioritize, quickly assess, manage multiple tasks and adapt to constantly changing situations.
• Excellent organizational skills. Strong detail orientation.
• Strong Microsoft Office skills. Excellent oral and written communication skills and interpersonal skills.
• Ability to work independently and make clinical decisions.
• Experience using MS Office and other Windows based computer applications.
• Ability to receive phone calls from prior authorization pharmacy technicians and/or providers for clinical information.
• Active pharmacist license that is in good standing in the state of residence.

Responsibilities

• Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements.
• Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols.
• Guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes.
• Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations.
• Establishes and maintains communication among CVS Caremark, health plan, and employer group staff.
• Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business.
• Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed.

Preferred Qualifications

• PGY1/PGY2
• Prior authorization, call center and clinical experience.
• Exposure to clinical and analytical problem solving.
• Ability to consult with pharmacy technicians and/or physicians regarding use of medications and advise of appropriate formulary alternatives when requested.