Clinical Pharmacy Review Specialist

Presbyterian System Services; Santa Fe (NM); Hybrid; MXN 514,000 - 875,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Disability insurance

Life insurance

Job summary

Presbyterian Healthcare Services is hiring a Clinical Pharmacy Review Specialist to support the Pharmacy Services Department. This remote role, based in New Mexico, focuses on clinical data preparation for coverage determinations and prior authorizations.

The successful candidate will perform initial reviews, gather information from physicians, and assist pharmacists with second-level reviews, all while ensuring regulatory compliance and efficient processing of claims.

Qualifications

• GED or High School diploma is required.
• Certified Pharmacy Technician-PTCB is required.
• Experience with pharmacy benefits management or prescription benefits is preferred.
• Experience with Medicare Part D and Medicaid programs is preferred.

Responsibilities

• Provide clinical support for the Pharmacy Services Department during clinical case reviews.
• Prepare and research data for coverage determinations, prior authorizations, and appeals.
• Perform first level review of prior authorization requests for eligibility and policies.
• Request additional information from physicians to establish medical necessity.
• Enter and interpret documentation in the claims processing system.
• Communicate benefit coverage details to members, providers and staff.

Skills

Communication

HIPAA rules

Pharmacy terminology

Medicare Part D

Education

GED/HS diploma

PTCB certification

Job description

Location Address

Remote Office Santa Fe, NM 87501

Compensation Pay Range

Minimum Offer $20.10

Maximum Offer $34.21

Now Hiring: Clinical Pharmacy Review Specialist

Summary

Build your Career. Make a Difference. Presbyterian is hiring a skilled Clinical Pharmacy Review Specialist to join our team.

Type of Opportunity

Full time

Job Exempt

No

Job is based

Remote Workers New Mexico

Work Shift

Days (United States of America)

Responsibilities

• The Clinical Pharmacy Review Specialist works under the direct supervision of a Clinical Pharmacist within the Pharmacy Services Department.
• This position is responsible for providing clinical support for the Fluent Health Pharmacy Services Department surrounding clinical case review submissions. This includes preparing and researching clinical data for coverage determinations, prior authorizations, direct member reimbursement, point of sale determinations, and appeals and grievances.
• Some key responsibilities include:
• Preforms first level review and evaluation of prior authorization requests for appropriateness, deviation from established medical standards policies, medical contraindications, coverage criteria or protocols
• Completes documentation review and requests additional information from prescribing physicians to establish medical necessity and forwards to clinical pharmacists for second level review.
• Ability to apply critical thinking skills and use reference documents, clinical criteria, policies and procedures and desktop procedures to complete tasks
• Assign, enter and interpret submitted documentation regarding prior authorization requests into appropriate claims processing system.
• Ability to communicate information to members, providers, pharmacists and pharmacy staff on issues related to benefit coverage, formulary, non-formulary criteria, or respective policies and procedures.
• Knowledge of drug nomenclature, basic pharmacology, dosage calculations, units of measure, prescription filling techniques, prescription documentation requirements, pharmacy laws and regulations, basic managed care pharmacy principles and insurance coverage issues.
• Knowledge of Pharmaceutical products, including oral, injectable, infusion products and chemotherapy drugs.
• Respond to member inquiries on the phone or on line requests for pharmacy coverage inquiries
• Effective oral and written communication skills.
• Ability to analyze rejected pharmacy claims and identify resolution for successful claims submission and processing.
• May perform activities that require evaluation or interpretation of information related to drug administration and treatments.
• Assist Clinical Pharmacist in review of Members medication regimen and assist in Medication Therapy Management
• Ability to meet established deadlines timely, accurately and with a sense of urgency
• Responsible for knowing and interpreting pharmacy and medical benefits.
• Knowledge of Medical terminology and HIPAA regulations
• Perform other duties as assigned.

Qualifications

• GED or High School diploma is required.
• Certified Pharmacy Technician-PTCB is required
• Experience with pharmacy benefits management, health insurance and or prescription benefits is preferred
• Retail Pharmacy experience preferred
• Managed care customer service experience preferred
• Drug Information skills
• Experience with Medicare Part D insurance and Medicaid programs

Benefits

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness

Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well‑being. Earn gift cards and more by taking an active role in our personal well‑being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services

Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services