Coverage Review Pharmacist

Job Description

Duties and Responsibilities:

• 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.
• 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 & Experience:

• Doctor of Pharmacy (PharmD) Degree.
• 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.