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Position Title: Clinical Pharmacist 1
Work Location: Remote
Assignment Duration: 3 Months
Work Schedule: 9am – 6pm EST No OT
Position Summary:
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| Typical Day in the Role | |
| • Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician’s recommended denial, suggested formulary alternatives, comments and attachments for appropriateness. • Verifies member’s ID number and date of birth. • Verifies member’s eligibility in the appropriate health plan eligibility system. • Records carrier and group number if applicable. • Checks for previous prior authorization decisions. • Verifies coverage in member’s prescription benefit when necessary. • Verifies coverage in member’s health plan benefit when necessary. • Evaluates prescription claim history. • Reviews chart notes and/or lab values. • Identifies provider specialty when appropriate. • Applies Medical Policy Criteria to prior authorization requests. • Evaluates whether request meets criteria for approval. • Reviews the request using professional clinical judgment on a case by case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested. • Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool • Communicates with physicians regarding prior authorization: o For a non-formulary drug o Plan benefits, exclusions o Quantity limits o Age restrictions o Formulary alternatives • Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department) • Compiles data for reporting purposes: o Drug utilization of non-formulary drugs o Overturned IPS recommended denials o Audit pharmacy claims greater than $200.00 o Suggest addition or deletion of drugs to/from the formulary o Updating qty/days or age limit ends o Support National P&T Committee o Other tasks which may arise during the performance of any of the above mentioned duties | |
Qualification & Experience:
| Candidate Requirements | ||||
| Education/Certification | Required: Pharm D. | Preferred: n/a | ||
| Licensure | Required: Any US state | Preferred: n/a | ||
| Must haves: At least one year of professional RPh experience Nice to haves: Some experience working in managed care, understanding of Medicare/Medicaid law Disqualifiers: n/a Performance indicators: • Sign 85 – 100 cases daily | |||
| 1 | Self-Motivated/Good Time Management Skills | ||
| 2 | Working Knowledge of Office Suite | |||
| 3 | Goal Oriented | |||