Title - Clinical Pharmacist
Duration - 3 months
Shift 9-6pm Monday to Friday | Local time
Location Remote
PR: XXXXXXXXXXX0-65.00/HR
Responsibilities
Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician s recommended denial, suggested formulary alternatives, comments and attachments for appropriateness.
Verifies member s ID number and date of birth.
Verifies member s eligibility in the appropriate health plan eligibility system.
Records carrier and group number if applicable.
Checks for previous prior authorization decisions.
Verifies coverage in member s prescription benefit when necessary.
Verifies coverage in member s health plan benefit when necessary.
Evaluates prescription claim history.
Reviews chart notes and/or lab values.
Identifies provider specialty when appropriate.
Applies Medical Policy Criteria to prior authorization requests.
Evaluates whether request meets criteria for approval.
Reviews the request using professional clinical judgment on a case by case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.
Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool
Communicates with physicians regarding prior authorization:
For a non-formulary drug
Plan benefits, exclusions
Quantity limits
Age restrictions
Formulary alternatives
Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department)
Compiles data for reporting purposes:
Drug utilization of non-formulary drugs
Overturned IPS recommended denials
Audit pharmacy claims greater than XXXXXXXXXXX
Suggest addition or deletion of drugs to/from the formulary
Updating qty/days or age limit ends
Support National P&T Committee
Other tasks which may arise during the performance of any of the above mentioned duties
Education/Certification Required : Bachelors / PharmD
Licensure Required: Current states pharmacist license
Years of experience required: Must haves: At least one year of professional RPh experience
Nice to haves: Some experience working in managed care, understanding of Medicare/Medicaid law
Skills :
Self-Motivated/Good Time Management Skills
Working Knowledge of Office Suite
Goal Oriented
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