Position Title: Clinical Pharmacist 1
Work Location: Remote
Assignment Duration: 3 Months - Possible extension
Work Schedule: 9am – 6pm EST No OT

Pharmacy Ops Dept includes PA and Appeals – Evaluate redetermination and appeals coverage requests

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:
  • For a non-formulary drug
  • Plan benefits, exclusions
  • Quantity limits
  • Age restrictions
  • Formulary alternatives
• Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department).
• Compiles data for reporting purposes:
  • Drug utilization of non-formulary drugs
  • Overturned IPS recommended denials
  • Audit pharmacy claims greater than $200.00
  • Suggest addition or deletion of drugs to/from the formulary
  • Updating qty/days or age limit ends
  • Support National P&T Committee
  • 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
Years of experience required Disqualifiers Best vs. average Performance indicators		Ideal candidates are:   Self-motivated Metric driven (retail experience can be an indicator of this but not always) ---what are the metric goals in their current role?  How many cases per day do they complete? ---this is crucial information if they are working in a prior auth role or have worked prior auth before Easily adaptable to frequent change Any experience with our systems (MHK, ESI, Micromedex, AHFS to name a few) Minimal gaps in employment history Licensure in the following states COULD be a plus – NC, IN, WA, NH, GA   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
Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection		1	Self-Motivated/Good Time Management Skills
		2	Working Knowledge of Office Suite
		3	Goal Oriented

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.This position's pay range is $60.00/hr - $62.00/hr.