Clinical Pharmacist

Software Galaxy Systems, LLC

28 days ago
Remote

$54–$56 Per Hour
Full-time

Highlights

This role will work from Client’s supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Auth team and member services department, as well as provide on-call after hours availability for urgent PA request as needed. The Pharmacist/Clinician is an operation-based role that conducts criteria based & clinical review of medical data collected to perform prior authorization as per policy and procedure.

Numbers & Facts

Location	( Remote)
Job Type	Full-time
Salary	$54–$56 Per Hour
Year Founded	null

Description

The Pharmacist/Clinician is an operation-based role that conducts criteria based & clinical review of medical data collected to perform prior authorization as per policy and procedure.
The Pharmacist/Clinician will apply clinical knowledge to plan approved criteria for reviews of cases.
This role will work from Client’s supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Auth team and member services department, as well as provide on-call after hours availability for urgent PA request as needed.

Job Responsibilities

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. One of the crucial responsibilities is to 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. (60%)
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. 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. (25%)
Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Specialty line of business.(10%)
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.(5%)
Active Pharmacist License
2+ years of Prior Authorization review experience
PBM, Managed Care, or Health Plan experience strongly preferred
Specialty Pharmacy experience is a plus
Comfortable with high-volume inbound and outbound provider interaction
Approximately 50 calls per day
Able to manage approximately 40 prior authorization cases per day
Proven remote work experience
Strong communication and documentation skills
Available for the full training period
Comfortable working one weekend day each week

Qualifications

Bachelor's degree in pharmacy or Pharm D. required.
Must have an active license in good standing in state of residence.
2+ years of Prior Authorization review experience