Remote 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

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.