Coverage Review Pharmacist

BlueCross BlueShield of Tennessee; United States; On-site; USD 110,000 - 140,000; Full time

Job summary

BCBST BlueCross BlueShield of Tennessee, Inc. is seeking a pharmacist to perform prospective and retrospective coverage reviews and appeals in accordance with state and federal regulations.

The role includes acting as a clinical resource to resolve mid-level reviews with limited supervision and maintaining denial rationale to ensure letters meet regulatory guidance. You will participate in an alternating team on-call rotation and contribute to compliance with FDA, NCQA, EQRO, and CMS guidelines

Qualifications

• PharmD degree required; Tennessee license or eligibility within 120 days.
• Minimum 3 years clinical experience or completion of 1 year residency and/or board certification.
• Ability to work independently with minimal supervision or in a team environment.
• Strong knowledge of regulatory guidelines (FDA, NCQA, EQRO, CMS).
• Proficiency in Microsoft Office Suite.

Responsibilities

• Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations.
• Serves as a clinical resource to aid in solving basic to mid-level reviews with limited assistance and supervision.
• Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance and guidance.
• Participates in alternating team on-call rotation.

Skills

Independent work

Compendia navigation

Microsoft Office

Team player

Oral & written communication

Interpersonal skills

Regulatory knowledge (FDA, NCQA, EQRO,

CMS knowledge

Pharmacy knowledge

Education

Doctor of Pharmacy (PharmD) Degree

Tools

Microsoft Office

Job description

Job Duties & Responsibilities

• Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations.
• Serves as a clinical resource to aid in solving basic to mid-level reviews with limited assistance and supervision.
• Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance and guidance.
• Participates in alternating team on-call rotation.

• Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations.
• Serves as a clinical resource to aid in solving basic to mid-level reviews with limited assistance and supervision.
• Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance and guidance.
• Participates in alternating team on-call rotation.

Job Qualifications

Education

• Doctor of Pharmacy (PharmD) Degree

Experience

• 3 years - Clinical experience required, and/or completion of 1 year residency and/or board certification

Skills\Certifications

• Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
• Competency in compendia navigation and research
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Must be a team player, be organized and able to to handle multiple projects
• Excellent oral and written communication skills
• Strong interpersonal and organizational skills
• Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required
• Knowledge of medical and pharmacy products

License

• Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy within 120 days of employment

Number of Openings Available

1

Worker Type

Employee

Company

BCBST BlueCross BlueShield of Tennessee, Inc.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.