Clinical Pharmacy Review Specialist

Presbyterian Healthcare Services • Remote Workers New Mexico, NM

4d • $20 - $34 • Remote

About The Position

The Clinical Pharmacy Review Specialist works under the direct supervision of a Clinical Pharmacist in the Pharmacy Services Department. The role provides clinical support for the Fluent Health Pharmacy Services Department by preparing and researching clinical data for coverage determinations, prior authorizations, direct member reimbursement, point-of-sale determinations, appeals, and grievances. The position is full-time, non-exempt, remote for workers in New Mexico, and works days.

Requirements

• GED or high school diploma.
• Certified Pharmacy Technician credential through PTCB.
• Knowledge of drug nomenclature, basic pharmacology, dosage calculations, units of measure, prescription-filling techniques, prescription documentation requirements, pharmacy laws and regulations, managed-care pharmacy principles, and insurance coverage issues.
• Knowledge of pharmaceutical products, including oral, injectable, infusion, and chemotherapy drugs.
• Effective oral and written communication skills.
• Knowledge of medical terminology and HIPAA regulations.

Nice To Haves

• Experience with pharmacy benefits management, health insurance, or prescription benefits.
• Retail pharmacy experience.
• Managed-care customer service experience.
• Drug information skills.
• Experience with Medicare Part D insurance and Medicaid programs.

Responsibilities

• Perform first-level review and evaluation of prior authorization requests for appropriateness, deviations from established medical standards and policies, medical contraindications, coverage criteria, and protocols.
• Review documentation and request additional information from prescribing physicians to establish medical necessity; forward cases to clinical pharmacists for second-level review.
• Apply critical-thinking skills and use reference documents, clinical criteria, policies, procedures, and desktop procedures to complete tasks.
• Assign, enter, and interpret submitted prior authorization documentation in the appropriate claims processing system.
• Communicate with members, providers, pharmacists, and pharmacy staff about benefit coverage, formulary and non-formulary criteria, and applicable policies and procedures.
• Respond to member pharmacy-coverage inquiries by phone or online.
• Analyze rejected pharmacy claims and identify ways to resolve them for successful claims submission and processing.
• Assist the Clinical Pharmacist with reviewing members’ medication regimens and with Medication Therapy Management.
• Meet established deadlines accurately and with a sense of urgency.
• Know and interpret pharmacy and medical benefits.
• Perform activities that may require evaluating or interpreting information related to drug administration and treatments.
• Perform other duties as assigned.

Benefits

• Medical, dental, and vision coverage.
• Short-term and long-term disability insurance.
• Group term life insurance.
• Other optional voluntary benefits.
• Employee Wellness rewards program, with opportunities to earn gift cards and other rewards through wellness activities.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED