Remote Clinical Pharmacist: Prior Authorization Expert

Centene Management Company LLC; Town of Florida (NY); Hybrid; USD 108,000 - 199,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Flexible work arrangements (remote/hyb

Job summary

Centene Management Company LLC is hiring a Clinical Pharmacist to process prior authorization requests for non-formulary medications and ensure clinically appropriate, cost-effective therapies for members.

The role requires a Pharmacist license in the employment state and at least one year of experience, with periodic weekend/holiday coverage rotation to support business needs. Benefits include competitive pay and comprehensive plans.

Qualifications

• Bachelor’s or Doctorate of Pharmacy degree.
• One year prior experience.
• Must have and maintain current, valid and unrestricted Pharmacist license in the state of employment.

Responsibilities

• Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician’s recommended denial, suggested formulary alternatives, comments and attachments for appropriateness.
• Verifies member’s ID number and date of birth.
• Verifies member’s eligibility in the appropriate health plan eligibility system.
• Records carrier and group number if applicable.
• Checks for previous prior authorization decisions.
• Verifies coverage in member’s prescription benefit when necessary.
• Verifies coverage in member’s health plan benefit when necessary.
• Evaluates prescription claim history.
• Reviews chart notes and/or lab values.
• Identifies provider specialty when appropriate.
• Applies Medical Policy Criteria to prior authorization requests.
• Evaluates whether request meets criteria for approval.
• Reviews the request using professional clinical judgment on a case by case basis.
• A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.
• Researches and contributes drug references and clinical information to facilitate prior authorization review.
• Communicates with physicians regarding prior authorization: For a non-formulary drug Plan benefits, exclusions Quantity limits Age restrictions Formulary alternatives.
• Retrieves and collects data through available reporting resources and compiles data for reporting purposes: Drug utilization of non-formulary drugs.
• Overturned IPS recommended denials.
• Audit pharmacy claims greater than $200.00.
• Suggest addition or deletion of drugs to/from the formulary.
• Updating qty/days or age limit ends.
• Support National P&T Committee.
• Other tasks which may arise during the performance of any of the above mentioned duties.

Skills

Prior authorization

Managed care

Clinical review

Pharmacist judgment

Education

Doctorate of Pharmacy

Job description

Centene Management Company LLC is hiring a Clinical Pharmacist to process prior authorization requests for non-formulary medications and ensure clinically appropriate, cost-effective therapies for members.

The role requires a Pharmacist license in the employment state and at least one year of experience, with periodic weekend/holiday coverage rotation to support business needs. Benefits include competitive pay and comprehensive plans.