Clinical Review Pharmacist

MedOne Pharmacy Benefit Solutions • Dubuque, IA

2d • Remote

About The Position

Position Overview:
MedOne is seeking a clinically skilled, detail-oriented pharmacist to support prior authorization reviews, consult with providers, evaluate drug literature, and collaborate across teams to ensure high-quality, guideline-based coverage determinations.

About MedOne:
MedOne is a full-service pharmacy benefit manager (PBM), serving clients and members nationwide. With a fully transparent, pass-through model, MedOne helps people conveniently access the most appropriate prescriptions at the most affordable price.

Requirements

• Pharmacy degree from an accredited school of pharmacy
• Registered Pharmacist with a state license in good standing
• Proficient in Microsoft Office Suite and experience using clinical resources (Micromedex, Lexicomp, Clinical Pharmacology)
• Ability to translate clinical information into a manner appropriate for both clinical and non-clinical audiences
• High degree of emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
• Detail-oriented with a high degree of accuracy.
• Strong interpersonal, written, and verbal communication skills.
• Ability to work independently and manage time effectively.
• Excellent customer service and teamwork skills
• Must have a designated workplace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) due to PHI and is protected from noise that could disrupt conversations.

Nice To Haves

• PGY1 Managed Care Residency (preferred)
• Familiarity with data entry software or CRM systems (Microsoft Dynamics) is a plus.

Responsibilities

• Evaluate, review and interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering coverage determinations (approvals, part approvals, denials)
• Perform and completes outbound clinical consult calls with physicians, healthcare providers and/or patients to as requested to answer inquiries regarding determinations
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations that are outside clinical guideline criteria
• Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides
• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements
• Provide mentorship to the Clinical Review Technician team as required.
• Assist Member Advocate and Account Management teams with patient or provider requests requiring pharmacist intervention.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Ph.D. or professional degree
• Number of Employees: 11-50 employees