Clinical Pharmacist, Coverage Determination

VIVA HEALTH; Alabama; Hybrid; USD 110,000 - 140,000; Full time

Benefits offered by this job

Health coverage

401(k) plan

Paid time off

Holidays & floating day

Tuition assistance

Flexible spending accounts

Community service time off

Life insurance

Wellness program

Training & development

Employee assistance program

Job summary

VIVA HEALTH in Alabama is seeking a Clinical Pharmacist, Coverage Determination, to lead clinical pharmacy decisions within the health plan. The role serves as a clinical reviewer for Commercial employer groups and Medicare Part D determinations, ensuring alignment with policy and CMS requirements.

The position requires Alabama pharmacist licensure (PharmD) or active RPh license, strong IT skills including Microsoft Office, and excellent written and oral communication.

Qualifications

• Registered Pharmacist (Rph) or Doctor of Pharmacy (PharmD) and Alabama license.
• Proficient computer skills including Microsoft Office.
• Excellent oral and written communication skills.

Responsibilities

• Perform Coverage Determination reviews for Medicare and Commercial lines.
• Research individual cases and render decisions with Pharmacy department leaders or Medical Director input.
• Assist in maintaining criteria for coverage determinations, exception requests, complaints, and appeals, and ensure criteria and decisions are properly communicated and applied.
• Assist department management in the development and maintenance of coverage determination decision trees.
• Ensure processes are carried out in accordance with CMS and other regulatory requirements.

Skills

Oral and written communication

Education

Pharmacist (PharmD) or Alabama-licensed pharmacist

Tools

Microsoft Office

Job description

Work Schedule: Hybrid or mostly remote schedule, depending on candidate preference and proximity to the VIVA HEALTH corporate headquarters. Candidate must reside within the State of Alabama.

The Clinical Pharmacist, Coverage Determination will provide leadership at the health plan regarding clinical pharmacy decisions and programs. This position will serve as a clinical reviewer for the Plan’s Commercial (employer groups) and Medicare Part D Coverage Determinations.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits

Key Responsibilities

• Perform Coverage Determination reviews (prior authorizations, formulary exceptions, etc.) for both Medicare and Commercial lines of business. Reviews will be completed in accordance with applicable policies and procedures, regulations, and guidelines.
• Research individual cases and render decisions with Pharmacy department leaders or Medical Director input as needed.
• Assist in maintaining criteria for pharmacy related coverage determinations, exception requests, complaints, and appeals, and ensure criteria and decisions are properly communicated and applied.
• Assist department management in the development and maintenance of coverage determination decision trees.
• Assist in ensuring processes are carried out in accordance with Centers for Medicare & Medicaid Services (CMS) and other regulatory requirements.

REQUIRED:

• Registered Pharmacist (Rph) or Doctor of Pharmacy (PharmD)
• Licensed Pharmacist in good standing with the State of Alabama
• Good computer skills including Microsoft suite of products
• Excellent oral and written communication skills

PREFERRED:

• 5 years’ experience in Medicare Advantage Coverage Determinations, health plan, or pharmacy benefits management