Clinical Pharmacist - Medicaid Prior Authorization (NC or MA Licensed)

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This position is for a Clinical Pharmacist working in the Medicaid Prior Authorization team. This remote position requires active, unrestricted pharmacist licensure in the State of North Carolina or State of Massachusetts.

The Clinical Pharmacist will:

• 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 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.

Working hours for this role will be 11:30am-8pm ET M-F, with a weekend on-call rotation.

We offer a competitive benefit package including vacation, 10 paid holidays per year, health/dental/vision insurance, employee discounted stock purchase program, 401K, tuition reimbursement, and 20-30% employee discount at all CVS stores.

 This is a remote role open to candidates within the United States. Candidate can reside in any state, but must hold active Pharmacist licensure in the State of North Carolina and/or State of Massachusetts and be willing to work 11:30am-8pm ET.

Required Qualifications

• Active pharmacist license that is in good standing in the state of North Carolina or state of Massachusetts

• Demonstrated experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology

• Prior authorization, call center and clinical pharmacy experience.

• Ability to prioritize, quickly assess, manage multiple tasks and adapt to constantly changing situations.

• Excellent organizational skills. Strong detail orientation.

• Strong Microsoft Office skills. Excellent oral and written communication skills and interpersonal skills.

• Ability to work independently and make clinical decisions.

• Experience using MS Office and other Windows based computer applications.

• Ability to receive phone calls from prior authorization pharmacy technicians and/or providers for clinical information.

• Flexibility with working a rotating schedule including overtime, weekends, and holidays

Preferred Qualifications

• PGY1/PGY2

• Exposure to clinical and analytical problem solving.

• Ability to consult with pharmacy technicians and/or phys