Clinical Pharmacist - Prior Authorization

CVS Health; Louisiana (MO); Hybrid; USD 130,175,000 - 218,201,000; Full time

Job summary

CVS Health is seeking a Clinical Pharmacist for the Prior Authorization team. The role supports referrals, clinical data collection, and determinations per plan criteria while coordinating with physicians and health plans.

This is a remote position across the United States with a 40-hour week. Requires active pharmacist license and Caremark PA Ops experience, plus proficiency in Microsoft Office and strong communication skills.

Qualifications

• Active pharmacist license (unrestricted).
• Current pharmacist experience within Caremark PA Ops.
• Ability to handle flexible hours including overtime, weekends, holidays.
• Proficient with Microsoft Office Suite (Excel/Word); familiarity with Access/Outlook/PowerPoint/Visio preferred.
• Strong written and verbal communication; ability to work in a team.

Responsibilities

• Process referrals and perform clinical assessments per criteria and SLAs.
• Render coverage determinations based on clinical criteria and plan design.
• Communicate decisions promptly to providers, plans, employers, patients, and staff.
• Handle inbound/outbound calls to facilitate prior authorization requests and resolve escalations.
• Maintain communication among CVS Caremark, health plans, and employer group staff.
• Maintain knowledge of drug/disease states for Specialty and Non-Specialty programs.
• Attend trainings and provide on-call/after-hours pharmacist availability.

Skills

Pharmacist licensure

Caremark PA Ops experience

Multitasking

Microsoft Office

Communication

Team mentorship

PHI confidentiality

Education

BS in Pharmacy or PharmD

Tools

Excel

Word

Access

Outlook

PowerPoint

Visio

Job description

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Position Summary

This position is for a Clinical Pharmacist working in the Prior Authorization team.

• 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.
• 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.
• 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.
• Establishes and maintains communication among CVS Caremark, health plan, and employer group staff.
• Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business.
• 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.

This is a remote role open to qualified candidates within the United States.

Required Qualifications

• Active, unrestricted pharmacist licensure
• Current pharmacist experience within Caremark PA Ops required
• Ability and willingness to work a flexible hourly schedule to include overtime, weekends, and holidays as needed
• Knowledge of Microsoft Office Suite: Excel and Word required; Access, Outlook, PowerPoint, Visio preferable. Keyboard skills essential.
• Must be able to multitask and utilize multiple system applications simultaneously.
• Must be able to utilize available resources independently and provide high quality work.
• Must demonstrate problem solving ability and attention to detail.
• Ability to adapt and change with workflow and shifting priorities.
• Ability to work effectively in a team environment and provide mentorship to non-clinical staff on the prior authorization team.
• Must possess excellent written, verbal, grammar, and listening communication skills.
• Must be able to effectively communicate with a diverse customer base (internal and external) in a friendly and confident manner.
• Ability to maintain confidentiality of PHI

Education

BS in Pharmacy or Pharm D

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$45.43 - $76.15

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.