Remote Coverage Review Pharmacist

Remote Coverage Review Pharmacist needs 3 years and Doctor of Pharmacy (Pharm

D) Degree

• Clinical experience required, and/or completion of 1 year residency and/or board certification
• 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 Power point)
• 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 License Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy

• 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