Clinical Pharmacist

not applicable; United States; On-site; USD 76,000 - 77,000; Full time

Job summary

CVS Caremark is seeking a Pharmacist/Clinician to perform criteria-based clinical reviews for prior authorization. You will work from CVS Caremark supported systems and handle inbound calls from physicians or members regarding pending, approved, or denied PA requests.

The role supports the Prior Auth and member services teams and requires after-hours pharmacist availability. Strong communication, organization, and knowledge of drug/disease states are essential for success.

Qualifications

• Previous pharmacy experience in PBM preferred.
• Basic computer skills required.
• Strong organizational skill, interpersonal skills and detail orientation important for this position.

Responsibilities

• Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design.
• Collaborate with technicians and team members to process referrals and collect data for assessments.
• Maintain knowledge of drug and disease states for specialty and non-specialty programs.
• Attend training, participate in meetings, and provide on-call after-hours pharmacist availability.

Skills

Prior Authorization review

Communication skills

Organizational skills

Detail-oriented

Education

BS Pharmacy degree

Active pharmacist license

Job description

Hours:8 hrs. in a day 40 hrs. in a week (Mon- Fri)

Pay Rate: $55-56/hr. on W2

Position Summary:

• 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 CVS Caremark 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.

Duties

1.) 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%)

2.) 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%)

3.) 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%)

4.) 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%)

Experience:

• Previous pharmacy experience in PBM preferred.
• Basic computer skills required.
• Strong organizational skill, interpersonal skills and detail orientation important for this position.

Prior Work Experience:

• Required: 1 to 3 years
• Preferred: 3 to 5 years

Ideal Candidate Profile

• 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
• Able to manage approximately 40 prior authorization cases per day
• Strong communication and documentation skills
• Available for the full training period
• Comfortable working one weekend day each week

Education:

• Required: Bachelor's Degree - BS Pharmacy and an active pharmacist license in the state of practice/residence.