Coverage Review Pharmacist

Job Description

Job Summary:

• Responsible for various activities associated with coverage reviews and appeals including the review of medication related prior authorizations, pharmacy appeals, and member grievances focused on medications.

Duties and Responsibilities:

• Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations Responds to prescriber, pharmacy provider, member appeals, grievances and complaints related to the provision of pharmaceutical services within established time periods.
• Builds and maintains decision trees in the prior authorization system.
• Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance.

Education:

• Doctor of Pharmacy (PharmD) Degree.

Experience:

• 3 years – Clinical experience required, and/or completion of 1 year residency and/or board certification.

License:

• Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy.

Knowledge, Skills and Abilities:

• 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 have the ability to handle multiple projects.
• Excellent oral and communication skills.
• Strong interpersonal and organizational skills.
• Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required.
• Knowledge of medical and pharmacy products.
• All applicants will be advised that Client, as a federal contractor, may be required to implement a COVID-19 vaccine mandate.