Clinical Pharmacist, Coverage Determination
About The Position
The Coverage Determination Pharmacist will provide leadership at the health plan regarding clinical pharmacy decisions and programs. This position will serve as a clinical reviewer for the Plan’s Commercial (employer groups) and Medicare Part D Coverage Determinations. VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys. VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.
Requirements
- Registered Pharmacist (Rph) or Doctor of Pharmacy (PharmD)
- Licensed Pharmacist in good standing with the State of Alabama
- Excellent oral and written communication skills
- Good computer skills including Microsoft suite of products
Nice To Haves
- 5 years’ experience in Medicare Advantage Coverage Determinations, health plan, or pharmacy benefits management
Responsibilities
- Perform Coverage Determination reviews (prior authorizations, formulary exceptions, etc.) for both Medicare and Commercial lines of business.
- Reviews will be completed in accordance with applicable policies and procedures, regulations, and guidelines.
- Research individual cases and render decisions with Pharmacy department leaders or Medical Director input as needed.
- Assist in maintaining criteria for pharmacy related coverage determinations, exception requests, complaints, and appeals, and ensure criteria and decisions are properly communicated and applied.
- Assist department management in the development and maintenance of coverage determination decision trees.
- Assist in ensuring processes are carried out in accordance with Centers for Medicare & Medicaid Services (CMS) and other regulatory requirements.
Benefits
- Comprehensive Health, Vision, and Dental Coverage
- 401(k) Savings Plan with company match and immediate vesting
- Paid Time Off (PTO)
- 9 Paid Holidays annually plus a Floating Holiday to use as you choose
- Tuition Assistance
- Flexible Spending Accounts
- Healthcare Reimbursement Account
- Paid Parental Leave
- Community Service Time Off
- Life Insurance and Disability Coverage
- Employee Wellness Program
- Training and Development Programs to develop new skills and reach career goals
- Employee Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
