Remote Appeals Pharmacist – Clinical Coverage & Decisions

Judi Health, LLC; Northern (KY); Hybrid; USD 102,000 - 133,000; Full time

Job summary

Judi Health is seeking a Clinical Appeals Reviewer to review coverage determinations and appeals for Commercial and Medicare lines, ensuring medical necessity and adherence to guidelines. You will collaborate with Medical Directors, interpret guidelines, perform peer reviews, and document decisions with thorough detail, while maintaining turnaround times in a remote environment.

This remote role allows you to work from a secure home office in the United States, handling high-volume cases with

Qualifications

• 1+ years prior authorization review or appeals experience required.
• Ability to work independently with minimal supervision in a remote, high-volume environment with shifting priorities.
• Have a designated secure workspace during work hours.
• Strong oral and written communication skills required.
• Proficient in Microsoft Office Suite and experience using clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology).

Responsibilities

• Evaluate and review all appeals to render coverage determinations based on clinical criteria and medical necessity.
• Collaborate with internal and external Medical Directors by providing clinical data for reviews.
• Interpret clinical guideline criteria and render approvals/denials across appeals.
• Perform peer-to-peer reviews with providers when requested.
• Perform scientific literature evaluation to support decisions.
• Provide detailed documentation in prior authorization and appeals cases.
• Make determinations in accordance with medical necessity and guidelines within turnaround times.
• Maintain quality and productivity while meeting deadlines.
• Stay current on communications and updated processes.

Skills

Prior authorization

Appeals

Remote work

Oral & written communication

Microsoft Office

Clinical terminology

Tools

Micromedex

Lexicomp

Clinical Pharmacology

Job description

Judi Health is seeking a Clinical Appeals Reviewer to review coverage determinations and appeals for Commercial and Medicare lines, ensuring medical necessity and adherence to guidelines. You will collaborate with Medical Directors, interpret guidelines, perform peer reviews, and document decisions with thorough detail, while maintaining turnaround times in a remote environment.

This remote role allows you to work from a secure home office in the United States, handling high-volume cases with