Appeals Pharmacist (temp-to-hire)

Jobtailor; Deutschland; Vor Ort; EUR 65.000 - 90.000; Vollzeit

Zusammenfassung

Jobtailor is seeking an experienced Pharmacist to support prior authorization reviews and appeal determinations for health plans. You will work remotely in a high-volume, regulated environment, ensuring medical necessity criteria are met and documented.

Responsibilities include reviewing requests, performing peer-to-peer reviews, collaborating with Medical Directors, and providing accurate clinical data to support decisions.

Qualifikationen

• Active pharmacist license in good standing.
• Experience with prior authorization reviews and appeals is required.
• Ability to work independently in a remote, high-volume setting with shifting priorities.
• Ability to maintain a secure home workspace during work hours.
• Strong oral and written communication skills are essential.
• Proficiency with clinical resources such as Micromedex, Lexicomp, and Clinical Pharmacology.

Aufgaben

• Evaluate and render coverage determinations based on medical necessity.
• Handle inbound/outbound calls with providers and patients to facilitate appeals.
• Collaborate with Medical Directors and provide clinical data for reviews.
• Interpret guidelines and render approvals/denials across levels of appeals.
• Perform peer-to-peer reviews with providers when requested.
• Evaluate scientific literature to support decisions and recommendations.
• Document prior authorization and appeal cases thoroughly.
• Make determinations within turnaround time requirements.
• Maintain quality and productivity and stay updated on processes and HIPAA rules.
• Deliver excellent customer care in a fast-paced environment.
• Adhere to Code of Conduct and report noncompliance.

Kenntnisse

Prior authorization

Appeals experience

Clinical guidelines

Medical necessity

Documentation

Peer reviews

Coverage determinations

Oral communication

Written communication

Independent work

Remote work

Customer care

Attention to detail

Ausbildung

Active pharmacist license

Tools

Micromedex

Lexicomp

Clinical Pharmacology

Microsoft Office

Jobbeschreibung

Responsibilities

• Evaluate and review all appeal requests to render coverage determinations based on clinical criteria and medical necessity.
• Perform and handle inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations.
• Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria.
• Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals.
• Perform peer to peer reviews with providers when requested.
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers.
• Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides.
• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times.
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
• Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frames.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Requirements

• Active, unrestricted, pharmacist license required
• 1+ years prior authorization review or appeals experience required
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities
• Have a designated workplace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations
• Strong oral and written communication skills required
• Proficient in Microsoft Office Suite and experience using clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology)

Hard Skills

• prior authorization review
• appeals experience
• clinical guideline interpretation
• scientific literature evaluation
• clinical review
• medical necessity determination
• documentation
• peer to peer reviews
• coverage determinations

Soft Skills

• strong oral communication
• strong written communication
• independent work
• productivity in remote environment
• customer care
• problem resolution
• adaptability
• attention to detail

Certifications & Qualifications

• active pharmacist license