Clinical Pharmacist – Prior Authorization

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

📋 Description

• Work collaboratively with technicians and members of the prior authorization team to manage referrals, address clinical inquiries, and gather clinical/medical data for evaluations and reviews.

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

• Confirm insurance coverage and eligibility, interpret clinical guidelines, consult with physicians and healthcare providers, and utilize clinical expertise while adhering to departmental protocols.

• Communicate decisions regarding cases promptly to healthcare providers, health plans/employers, patients, and other healthcare professionals.

• Manage both inbound and outbound calls to facilitate prior authorization requests, respond to inquiries, and address escalations.

• Foster and maintain communication among CVS Caremark, health plan, and employer group personnel.

• Keep abreast of professional and technical knowledge related to drug and disease states for both Specialty and Non-Specialty Pharmacy programs.

• Participate in training sessions and development meetings.

• Provide on-call and after-hours pharmacist availability as required.

• Consult with pharmacy technicians and physicians regarding medication usage and suggest formulary alternatives when needed.

⛳️ Requirements

• A minimum of 2 years’ experience as a pharmacist within a PBM environment.

• Current experience with commercial Prior Authorizations at Caremark PBM.

• Proficient in utilizing clinical resources such as Micromedex, Lexicomp, and Clinical Pharmacology.

• Capability to prioritize, swiftly assess, manage multiple tasks, and adapt to evolving situations.

• Exceptional organizational skills with a strong attention to detail.

• Proficient in Microsoft Office applications.

• Outstanding oral and written communication skills, alongside strong interpersonal abilities.

• Ability to work autonomously and make clinical judgments.

• Experienced with MS Office and other Windows-based computer applications.

• Competence in receiving calls from prior authorization pharmacy technicians and/or providers for clinical information.

• Active pharmacist license in good standing in the applicant's state of residence.

• Bachelor of Science in Pharmacy or Pharm.D.

• Preferred: PGY1/PGY2 residency.

• Preferred: Experience in prior authorization, call center operations, and clinical settings.

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

🏝️ Benefits

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

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources aimed at supporting colleagues' physical, emotional, and financial well-being.

• Comprehensive benefits package for eligible full-time colleagues and their families.