Clinical Pharmacy Review Specialist - Coverage & MTM

Presbyterian Healthcare Services; Albuquerque (NM); On-site; USD 28,000 - 47,000; Full time

Benefits offered by this job

Wellness program

Comprehensive benefits package

Job summary

Presbyterian Healthcare Services in Albuquerque, NM seeks a Clinical Pharmacy Review Specialist to support the Pharmacy Services Department. You will perform clinical data reviews for coverage determinations, prior authorizations, and appeals, and you will interact with members, providers and staff to resolve coverage questions.

Key responsibilities include screening requests, gathering information from prescribers, and assisting pharmacists with medication therapy management.

Qualifications

• GED or high school diploma is required.
• Certified Pharmacy Technician (PTCB) certification is required.
• Experience with pharmacy benefits management or prescription benefits is preferred.

Responsibilities

• Performs first level review and evaluation of prior authorization requests for appropriateness, policy deviations, coverage criteria or protocols.
• Completes documentation review and requests information from prescribing physicians to establish medical necessity and forwards to clinical pharmacists for second level review.
• Enter and interpret submitted documentation regarding prior authorization requests into the appropriate claims processing system.
• Communicate information to members, providers, pharmacists and staff on issues related to benefit coverage and formulary criteria.
• Assist Clinical Pharmacist in review of members' medication regimens and support Medication Therapy Management.

Skills

Communication skills

Critical thinking

Clinical knowledge

Team collaboration

Education

GED or High School diploma

Certified Pharmacy Technician-PTCB

Job description

Presbyterian Healthcare Services in Albuquerque, NM seeks a Clinical Pharmacy Review Specialist to support the Pharmacy Services Department. You will perform clinical data reviews for coverage determinations, prior authorizations, and appeals, and you will interact with members, providers and staff to resolve coverage questions.

Key responsibilities include screening requests, gathering information from prescribers, and assisting pharmacists with medication therapy management.