Job Description:

• Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity.
• Perform and handle inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations.
• Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria.
• Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals.
• Perform peer to peer reviews with providers when requested.
• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers.
• Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides.
• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times.
• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
• Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frames.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Requirements:

• Active, unrestricted, pharmacist license required
• 1+ years prior authorization review or appeals experience required
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities
• Have a designated workplace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations
• Strong oral and written communication skills required
• Proficient in Microsoft Office Suite and experience using clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology)

Benefits:

• Health insurance
• Retirement plans
• Paid time off
• Flexible work arrangements