Medical Reviewer, Pharmacist

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

📋 Description

• Conduct clinical evaluations related to pharmacy and medications.

• Assist in the review and adjudication of pharmacy claims.

• Offer clinical expertise for drug utilization reviews and authorization requests related to medications.

• Aid in drug rebate initiatives and pharmacy program activities as tasked.

• Evaluate pharmacy documentation to ensure compliance with relevant policies and coverage criteria.

• Provide technical expertise and support concerning pharmacy reviews.

• Accurately and promptly document findings and recommendations.

• Collaborate with physicians, nurses, pharmacy teams, operations, and other healthcare professionals.

• Stay updated on relevant pharmacy policies and regulatory standards.

• Primarily work from a home office while supporting Medical Review Services for California's healthcare programs.

• Review pharmacy, clinical, claim, authorization, and related documentation.

• Navigate various computer systems and applications to complete reviews and document findings.

• Achieve established standards for quality, accuracy, productivity, and turnaround times.

⛳️ Requirements

• Valid and active pharmacist license from the State of California, in good standing.

• Must not be under suspension from Medicare, Medicaid, or pharmacy practice in California.

• Must not have a history of sanctions for fraud or abuse.

• A minimum of three (3) years of experience as a pharmacy consultant for a government or private-sector healthcare payer; or one (1) year of MMIS experience in a large state providing technical expertise and support for pharmacy reviews.

• Excellent oral and written communication skills.

• In-depth knowledge of pharmacy practices, medication reviews, and healthcare reimbursement processes.

• Maintain all professional licenses, certifications, and credentials required for the role in active, unrestricted, and good-standing status.

• Travel requirement: 0-10%.

🏝️ Benefits

• Flexible vacation policy.

• 401(k) employer match.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development programs.

• Flexible work hours.

• Remote work environment.

• Continuous training and support.

• Work-life balance.

• Opportunities for career development.