Coverage Review Pharmacist

BlueCross BlueShield of Tennessee • Chattanooga, TN

1d • Remote

About The Position

BlueCross BlueShield of Tennessee (BCBST) is expanding its clinical operations team and seeking to hire a Coverage Review Pharmacist to help ensure accurate, compliant, and evidence-based coverage decisions. In this role, you will leverage your clinical expertise to perform prospective and retrospective coverage reviews, including prior authorizations and appeals, for both self-administered and provider-administered medications. You will apply evidence-based clinical criteria along with state and federal regulatory requirements to ensure accurate, well-supported coverage determinations and denial rationales. As a key clinical resource, you’ll collaborate within a knowledgeable and highly organized team environment while working independently to apply sound clinical judgment. The ideal candidate brings a strong background in prior authorization decisioning and coverage reviews, with prior experience using NovoLogix or MHK systems is highly preferred. A solid understanding of regulatory and accreditation guidelines—including FDA, NCQA, EQRO, and CMS requirements—is required. This role is well suited for a pharmacist who values autonomous work, clinical rigor, regulatory compliance, and the opportunity to make a meaningful impact on patient access to care.

Requirements

• Doctor of Pharmacy (PharmD) Degree
• 3 years - Clinical experience required, and/or completion of 1 year residency and/or board certification
• Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
• Competency in compendia navigation and research
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Must be a team player, be organized and able to to handle multiple projects
• Excellent oral and written communication skills
• Strong interpersonal and organizational skills
• Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required
• Knowledge of medical and pharmacy products
• Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy within 120 days of employment

Nice To Haves

• Prior experience using NovoLogix or MHK systems is highly preferred.

Responsibilities

• Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations.
• Serves as a clinical resource to aid in solving basic to mid-level reviews with limited assistance and supervision.
• Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance and guidance.
• Participates in alternating team on-call rotation.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Ph.D. or professional degree