Clinical Pharmacist - Prior Authorization

CVS Health•Work At Home-Massachusetts, MA

4d•$56 - $93

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. Ready to take your Clinical Pharmacist skills to the next level with a Fortune 6 company? Check out this outstanding opportunity for a Clinical Pharmacist with CVS Health. This position is for a Clinical Pharmacist working in the Prior Authorization team.

Requirements

Active pharmacist license in the state of residence that is in good standing
Current experience as clinical Pharmacist within Caremark PA team
Demonstrated ability to utilize multiple software systems, simultaneously with a 2-screen workstation setup (Windows based operations, AS400, MHK, PeopleSafe, WI database, Microsoft office applications)
Ability to type 30 WPM or greater
Demonstrated pharmacist experience within PBM environment, including prior authorization experience
Excellent oral and written communication skills
Ability to multi-task, prioritize, and manage time effectively in a fast-paced, highly regulated environment
Must be able to review large volume of information, determine importance, and apply clinical knowledge to assist in outcome
Must be able to work independently and utilize critical thinking/problem solving skills to make case decisions
Receptive to constructive feedback and flexible in adapting to change
Flexibility with working a rotating schedule including overtime, weekends, and holidays.

Responsibilities

Collaborates 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.
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.
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.
Establishes and maintains communication among CVS Caremark, health plan, and employer group staff.
Maintains 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.
Performs 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.