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 the client supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Auth team and member services department, as well as provide on-call after hours availability for urgent PA request as needed.

Duties
1.) 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%)
2.) 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%)
3.) Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Specialty line of business.(10%)
4.) 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%)

Experience
Previous pharmacy experience in PBM preferred. Appropriate state license required. Basic computer skills required. Strong organizational skill, interpersonal skills and detail orientation important for this position.

Prior Work Experience:
Required: 1 to 3 years
Preferred: 3 to 5 years

Education
Required: Bachelor's Degree - BS Pharmacy and an active pharmacist license in the state of practice/residence.
Preferred: Doctorate - Pharm D

Ideal Candidate Profile
Active Pharmacist License
2+ years of Prior Authorization review experience
PBM, Managed Care, or Health Plan experience strongly preferred
Specialty Pharmacy experience is a plus
Comfortable with high-volume inbound and outbound provider interaction
Approximately 50 calls per day
Able to manage approximately 40 prior authorization cases per day
Proven remote work experience
Strong communication and documentation skills
Available for the full training period
Comfortable working one weekend day each week

Notes:
Fully remote (never coming onsite)
Shifts available (Sun-Thurs or Tues-Sat): Candidate MUST work CST hours, and MUST work one weekend day each week
10:30am-7pm CST
11am-7:30pm CST
11:30am-8pm CST
Training dates: October 12th - November 25th; training time: 8am to 4:30pm CST; first 7 weeks