Offer summary

Qualifications:

Pharm D. required with at least two years of experience as a pharmacist in a managed care environment., Active, unencumbered Pharmacist license in North Carolina is required., Experience in prior authorization, call center, and/or clinical pharmacy is essential., Strong organizational, communication, and computer skills, including proficiency in Microsoft Office..

Key responsibilities:

Evaluate and review prior authorization requests and render coverage determinations based on clinical criteria.

Collaborate with team members to process referrals and answer clinical questions.

Maintain professional knowledge of drug and disease states relevant to the pharmacy programs.

Handle inbound and outbound calls to facilitate prior authorization requests and resolve inquiries.

Job description

Shift: 8 hours shift between 11am to 730pm EST

Job Description:

Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols. One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes.
Collaborate with the technicians and prior authorization team members to process refer rals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer- agreed criteria within the designated service level agreements. Performs and handles in bound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations.
Maintain professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business.
Perform other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed.

Responsibilities:

This position is a 100% remote, work from home opportunity and will not be patient facing.
Demonstrated experience using clinical resources, e g., Micromedex, Lexicomp, Clinical Pharmacology
Ability to prioritize, quickly assess, manage multiple tasks and adapt to constantly changing situations.
Prior authorization, call center and/or clinical pharmacy experience.
Excellent organizational skills. Strong detail orientation.
Strong Microsoft Office skills.
Excellent oral and written communication skills and interpersonal skills.
Ability to work independently and make clinical decisions.
Experience using MS Office and other Windows based computer applications.
Ability to receive phone calls from prior authorization pharmacy technicians and/or providers for clinical information.

Experience:

Hold and maintain an active, unencumbered Pharmacist license in North Carolina.
Position requires proficiency with computer skills which include multitasking, navigating multiple systems, and keyboarding. Experience using MS Office, other Windows based computer applications, web based processing and telephony programs.
Minimum 2 years’ recent experience reviewing and processing prior authorizations against health plan criteria for a determination in a specialty/skilled clinical setting i.e., specialty medical office or Pharmacy Benefits Manager (PBM)

Skills:

MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
MUST HAVE 6 months of experienced with Prior Authorization(required).
MUST HAVE experience with Medicare Part D
Must Have Pharmacy Benefit Management (PBM) experience.

Education:

Pharm D. required with at least two years experience as a pharmacist in Managed care environment.
Must have an active license in the state of residence in good standing.

Screening Questionnaire:

How many years of prior-authorization experience do you have?
Haw many Prior Auth cases have you handled in your last role?
Do you have experience in handling calls regarding prior authorization and appeals?

About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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