Clinical Pharmacist – Appeals and Operations

This is a fully remote position, open to applicants in Massachusetts.

📋 Description

• Accountable for assessing and offering clinical judgments/recommendations regarding provider/member submitted appeals and grievances related to medically administered medications, in addition to pharmacy-related medications and items across all business lines.

• Work in partnership with the Appeals & Grievance Department, Medical Directors, and Prior Authorization vendors.

• Ensure turnaround times are met for all appeal and grievance evaluations.

• Analyze appeal/grievance requests based on plan-specific criteria, MassHealth-developed standards, National Coverage Determinations, Local Coverage Determinations, Evidence of Coverage, and Member Handbooks.

• Adhere to regulatory guidelines and processes for Massachusetts, CMS, Medicaid, and state Connector programs.

• Engage with internal and external stakeholders as necessary.

• Provide consultation to healthcare providers.

• Contribute to the management of clinical issue resolution; collaborate with medical providers and vendors to coordinate and address member concerns.

• Offer recommendations, when suitable, to revise current prior authorization criteria based on appeals and grievance data.

• Aid in the development of formulary and criteria across all business lines.

• Participate in general drug information support for both internal and external clients.

• Deliver clinical support to pharmacy personnel for daily operations.

⛳️ Requirements

• RPH or Pharm D License

• Valid, unrestricted pharmacist license in Massachusetts

• Minimum of 3 years of experience, with at least 1 year in a managed care setting; 1-2 years of professional experience as a clinical pharmacist is preferred.

• Recent experience involving member and/or provider appeals and drug coverage determinations is advantageous.

• Competent in evaluating clinical pharmacy data, coverage criteria, and drug monographs.

• Proficient in utilizing computer databases, EMRs, Excel, Word, PowerPoint, and other software.

• Capable of articulating clinical decisions effectively, both in writing and verbally, to physicians and other healthcare professionals.

• Exceptional communication, coordination, and planning skills, with the ability to engage with a diverse range of audiences to foster collaboration and consensus.

🏝️ Benefits

• Comprehensive health and wellness programs

• Opportunities for professional development and continuing education

• Competitive salary and performance-based incentives

• Flexible work arrangements

• Supportive team environment and culture