Pharmacist - Prior Authorizations
Duration: 6+ months contract Job Description:
- The clinical pharmacist is an operation based role that conducts clinical reviews of medical data collected to perform prior authorization for commercial and specialty medications.
- The clinical pharmacist will apply clinical knowledge to plan approved criteria for prospective and concurrent reviews of cases.
- This role will work from Virtual systems and take inbound calls from physician or members regarding their pending, approved, or denied prior authorizations.
Responsibilities:
- 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 referrals, 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 inbound 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 Medicaid, 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.
Experience:
- Prior experience with prior authorization (PA) reviews or clinical case review in a high-volume or production setting-look for direct experience processing PA requests, ideally with commercial or specialty pharmacy, and strong documentation of meeting service level agreements (SLAs) or production targets.
- Demonstrated ability to multitask using multiple technology platforms and clinical resources-seek candidates who highlight comfort with multitasking, proficiency with Microsoft Office (especially Excel and Word), and using multiple clinical and administrative systems at once.
- Strong communication and collaboration skills in cross-functional teams-prioritize resumes that show effective written and verbal communication, experience working with both clinical and non-clinical staff, and handling phone-based interactions with providers and patients.
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.
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. Apply tot his job Apply To this Job