Clinical Pharmacist - Prior Authorization

CVS Health

2d•$50 - $85•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. 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. - 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. We offer a competitive benefit package including vacation, 10 paid holidays per year, health/dental/vision insurance, employee discounted stock purchase program, 401K, tuition reimbursement, and 20-30% employee discount at all CVS stores. This is a remote role open to candidates within the United States.

Requirements

2 years’ experience working as a pharmacist in a PBM setting.
Current experience working with commercial Prior Authorizations in PBM
Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology
Ability to prioritize, quickly assess, manage multiple tasks and adapt to constantly changing situations.
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.
Active pharmacist license that is in good standing in the state of residence.

Nice To Haves

PGY1/PGY2
Prior authorization, call center and clinical experience.
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

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.
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.

Benefits

vacation
10 paid holidays per year
health/dental/vision insurance
employee discounted stock purchase program
401K
tuition reimbursement
20-30% employee discount at all CVS stores
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.