Clinical Pharmacist – Medicaid Prior Authorization, NC Licensed

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

📋 Description

• Assess and review prior authorization requests, making coverage decisions based on clinical criteria and plan specifications.

• Confirm insurance coverage and eligibility, interpreting clinical guideline criteria as necessary.

• Collaborate with physicians and other healthcare providers, utilizing clinical expertise and resources while adhering to departmental protocols.

• Promptly communicate case decisions to healthcare providers, health plans/employers, patients, and other healthcare professionals.

• Work in conjunction with technicians and prior authorization team members to handle referral processes.

• Address clinical inquiries and gather clinical/medical data for assessments and reviews in line with established criteria and service level agreements.

• Manage inbound and outbound communications with technicians, team members, physicians, healthcare providers, and patients.

• Facilitate prior authorization requests, respond to inquiries, and resolve escalated issues.

• Maintain up-to-date professional and technical knowledge regarding drug and disease states for both Specialty and Non-Specialty Pharmacy programs.

• Participate in training sessions and development meetings, providing on-call and after-hours pharmacist availability as required, including weekends.

⛳️ Requirements

• Must possess and uphold an active, unrestricted pharmacist license in good standing in North Carolina.

• Relevant experience with prior authorizations within Caremark PBM.

• Proven experience utilizing clinical resources such as Micromedex, Lexicomp, and Clinical Pharmacology.

• Experience in prior authorization, call centers, and/or clinical pharmacy settings.

• Proficient in Microsoft Office applications.

• Familiarity with MS Office and other Windows-based computer systems.

• Capability to prioritize, quickly evaluate, manage multiple tasks, and adapt to evolving situations.

• Exceptional organizational skills and meticulous attention to detail.

• Strong oral and written communication abilities, along with excellent interpersonal skills.

• Ability to work autonomously and make informed clinical decisions.

• Capacity to receive phone calls from prior authorization pharmacy technicians and/or providers regarding clinical information.

• Bachelor's of Science in Pharmacy or Pharm.D.

• Preferred: experience in clinical and analytical problem-solving.

• Preferred: ability to consult with pharmacy technicians and/or physicians on medication use and provide recommendations on formulary alternatives.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to the base salary range.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being, based on eligibility.