Medical Reviewer (Pharmacist) - Remote CA
About The Position
Gainwell Technologies is seeking a Medical Reviewer (Pharmacist) to provide pharmacy and clinical expertise supporting Medical Review Services for California healthcare programs. This role supports pharmacy review, claim adjudication, drug rebate activities, drug utilization review, Treatment Authorization Requests (TARs), and other Medical Review Services functions. This is a full-time, remote position with a Monday through Friday work schedule, primarily performed from your home office. The role involves reviewing pharmacy, clinical, claim, authorization, and supporting documentation, navigating multiple computer systems, and collaborating with various healthcare professionals. The position requires maintaining professional licenses and knowledge of applicable policies and regulatory guidelines, while meeting quality, accuracy, productivity, and turnaround-time expectations. Ongoing training and support are provided.
Requirements
- Current, non-expired pharmacist license from the State of California, in good standing.
- Must not be under suspension from Medicare, Medicaid, or pharmacy practice in California.
- Must not have been previously sanctioned for fraud or abuse.
- Three (3) years of previous experience as a pharmacy consultant for a government or private-sector healthcare payer; or one (1) year of MMIS experience in a large state providing technical expertise and assistance for pharmacy review.
- Strong oral and written communication skills.
- Strong knowledge of pharmacy practices, medication review, and healthcare reimbursement processes.
Responsibilities
- Perform pharmacy and medication-related clinical reviews.
- Support pharmacy claim review and adjudication activities.
- Provide clinical expertise for drug utilization review and drug-related authorization requests.
- Support drug rebate and pharmacy program activities as assigned.
- Review pharmacy documentation for compliance with applicable policies and coverage requirements.
- Provide technical expertise and assistance related to pharmacy review.
- Document findings and recommendations accurately and timely.
- Collaborate with physicians, nurses, pharmacy teams, operations, and other healthcare professionals.
- Maintain knowledge of applicable pharmacy policies and regulatory requirements.
- Spend the majority of your day reviewing pharmacy, clinical, claim, authorization, and supporting documentation.
- Navigate multiple computer systems and applications to complete reviews, document findings, and support timely determinations.
- Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status.
- Maintain knowledge of applicable medical and pharmacy policies, coverage requirements, clinical standards, and regulatory guidelines.
- Meet established quality, accuracy, productivity, and turnaround-time expectations.
- Receive ongoing training and support related to program requirements, systems, policies, and medical review processes.
Benefits
- flexible vacation policy
- 401(k) employer match
- comprehensive health benefits
- educational assistance
- leadership and technical development academies
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
