Clinical Pharmacist - Medicaid Prior Authorization (NC Licensed)

CVS Health • Raleigh, NC

9d • $45 - $76 • Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This position is for a Clinical Pharmacist working in the Prior Authorization team. This role requires candidates to currently hold and maintain active, unrestricted pharmacist licensure in the State of North Carolina. Candidate may reside in any state. This Pharmacist will: • Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols. One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes. • Collaborate with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements. Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations. • Maintain professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business. • Perform other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed. This is a remote role open to qualified candidates within the United States. Candidate can reside in any state, but must hold active Pharmacist licensure in the State of North Carolina.

Requirements

• Active, unrestricted pharmacist license that is in good standing in the state of North Carolina
• Demonstrated experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology
• Ability to prioritize, quickly assess, manage multiple tasks and adapt to constantly changing situations.
• Prior authorization, call center and/or clinical pharmacy experience.
• Excellent organizational skills. Strong detail orientation.
• Strong Microsoft Office skills.
• Excellent oral and written communication skills and interpersonal skills.
• Ability to work independently and make clinical decisions.
• Experience using MS Office and other Windows based computer applications.
• Ability to receive phone calls from prior authorization pharmacy technicians and/or providers for clinical information.

Nice To Haves

• Exposure to clinical and analytical problem solving.
• Ability to consult with pharmacy technicians and/or physicians regarding use of medications and advise of appropriate formulary alternatives when requested.

Responsibilities

• Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design.
• Collaborate with the technicians and prior authorization team members to process referrals
• Maintain professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business.
• Perform other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed.

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees