RPh Advisor - Commercial Specialty

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary:

The Pharmacist/Clinician is an operation-based role that conducts criteria based & clinical review of medical data collected to perform prior authorization as per policy and procedure. The Pharmacist/Clinician will apply clinical knowledge to plan approved criteria for reviews of cases. This role will work from CVS Caremark supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Authorization team and member services department, as well as provide on-call after hours availability for urgent Prior Authorization request as needed.

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. (60%)

Collaborates 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. (25%)

Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Commercial Specialty line of business.  Performs 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. (5%)

This is a remote role open to qualified candidates within the United States.

Education:

Required: BS Pharmacy

Preferred: Doctorate - Pharm D

Active, unrestricted pharmacist license required within state of practice/residence

Prior Work Experience:

Required: 1 to 3 years

Preferred: 3 to 5 years

Required Skills & Other Minimum Required Qualifications:

• Licensed Registered Pharmacist

• Current pharmacist experience within Caremark Commercial Specialty required

• Ability and willingness to work a flexible hourly schedule to include overtime, weekends, and holidays as needed

• Knowledge of Microsoft Office Suite: Excel and Word required; Access, Outlook, PowerPoint, Visio preferable.  Keyboard skills essential.

• Must be able to multitask and utilize multiple system applications simultaneously.

• Must be able to utilize available resources independently and provide high quality work.

• Must demonstrate problem solving ability and attention to detail.

• Ability to adapt and change with workflow and shifting priorities.

• Ability to work effectively in a team environment and provide mentorship to non-clinical staff on the prior authorization team.

• Must possess excellent written, verbal, grammar, and listening communication skills.

• Must be able to effectively communicate with a diverse customer base (internal and external) in a friendly and confident manner.

• Ability to maintain confidentiality of PHI (Protected Healthcare Information).

Essential Functions:

Regular an