Clinical Pharmacist Advisor Medicare- #26-23278

Creative Solutions Services, LLC; Woonsocket (RI); On-site; USD 110,000 - 140,000; Full time

Job summary

US Tech Solutions seeks a Pharmacist – Prior Authorization Advisor to evaluate PA requests, apply clinical criteria, and render coverage determinations. The role involves inbound/outbound calls with physicians, members, and providers, plus collaboration with the PA team to collect essential data.

The candidate must hold an active pharmacist license in their state, have PBM and managed care experience, and be able to work within defined SLAs.

Qualifications

• Must have Managed Care experience and Medicare/Medicaid knowledge.
• Must have at least 6 months of Prior Authorization experience.
• Pharmacy Benefit Management (PBM) experience is required.
• Active pharmacist license in state of residence in good standing.

Responsibilities

• Evaluate and review prior authorization requests and render coverage determinations based on clinical criteria.
• Collaborate with technicians and PA team to process referrals and gather clinical data.
• Maintain knowledge of drugs and disease states for Specialty and Non-Specialty Pharmacy programs.
• Provide on-call after-hours pharmacist availability as needed.

Skills

Managed care

Medicare/Medicaid knowledge

Prior Authorization experience

Education

Pharm D. with managed care experience

Job description

Duration: 11+ months contract

Shift: 7am to 10pm CST - 8 hours/day

Job Description:

• The Pharmacist – Prior Authorization Advisor 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 our 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.

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%)

Experience:

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

Skills:

• MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
• MUST HAVE 6 months of experienced with Prior Authorization(required).
• Must Have Pharmacy Benefit Management (PBM) experience.

Education:

• Pharm D. required with at least two years experience as a pharmacist in Managed care environment.

Licenses:

• Must have an active Pharmacist license in the state of residence in good standing.

About US Tech Solutions:

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

AI Statement:

By applying, you acknowledge that AI-assisted tools may be used during hiring.

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