Clinical Pharmacist

SGS Consulting; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

SGS Consulting in the United States is seeking a Clinical Pharmacist Advisor Medicare to support Medicare Part D members and providers with pharmacy benefits, ensuring accurate case setup and timely decisions.

You will review clinical information, perform outreach to providers when needed, and comply with Medicare guidance, compendia, CMS timelines, and quality standards to deliver best-in-class service.

Qualifications

• Bachelor's degree in pharmacy or PharmD. required. Must have an active license in good standing in state of residence.

Responsibilities

• Ensure accuracy of case setup and clinical review of Medicare appeals.
• Provide clear documentation and contact providers to obtain clinical details.
• Adhere to CMS timelines and Medicare guidelines.
• Support continuous improvement through supervisor feedback.

Skills

Clinical review

Provider outreach

Documentation

Medicare guidelines

Education

Bachelor's degree in pharmacy or PharmD

Tools

Drug compendia resources

Job description

• Shift: Business Hours are 7am - 8pm EST Monday - Friday and 7:00 am – 4:30pm EST Sat and Sunday. Set Rotation.

Position Summary:

• As a Clinical Pharmacist Advisor Medicare, you will be directly supporting Medicare Part D members and providers with requests related to their pharmacy benefits.
• You will be responsible for ensuring cases are accurately set up for our members, review clinical information for decisioning the request, performing outreach to providers for more information when needed, and ensuring accurate decisions that comply with compendia and Medicare guidance and timelines.
• This is a great opportunity to initiate a career with a leading healthcare company by reviewing information and completing timely and accurate documentation of all Medicare Part D requests, in compliance with Medicare guidelines, while promoting a best-in-class service experience.

Duties:

• The role involves ensuring the accuracy of case setup and clinical review of Medicare appeals cases by thoroughly reviewing internal notes or fax requests for pertinent information, providing clear and concise documentation, and contacting providers when necessary to obtain clinical details for case decisions.
• It requires adherence to work instructions and Medicare guidelines to ensure proper case processing.
• The position also demands compliance with CMS-mandated timelines, as well as departmental productivity and quality standards.
• Clinical judgment and knowledge must be applied effectively, utilizing drug compendia resources, evolving work instructions, and CMS Medicare guidance.
• Additionally, the role includes participating in development discussions and receiving feedback from the direct supervisor to support continuous improvement.

Experience:

• Previous experience in managed care, PBM environment, institutional healthcare, pharmacy, or related experience (preferred).

Education:

• Bachelor's degree in pharmacy or Pharm D. required. Must have an active license in good standing in state of residence.