Appeals Pharmacist - Remote

Overview

The Appeals Pharmacist is responsible for reviewing clinical coverage determination and appeals for various lines of business, ensuring efficiency and quality decision-making to meet client expectations.

In Short

• Evaluate and review all appeals requests based on clinical criteria.
• Collaborate with Medical Directors to provide clinical data.
• Interpret clinical guidelines for approvals and denials.
• Perform peer reviews with providers as needed.
• Conduct literature evaluations to support decision-making.
• Document prior authorization and appeals cases thoroughly.
• Make clinical prior authorization determinations.
• Maintain quality and productivity standards.
• Stay updated on communications and procedures.
• Deliver excellent customer care and service.

Requirements

• Active, unrestricted pharmacist license required.
• 1+ years of prior authorization review or appeals experience.
• Ability to work independently in a remote environment.
• Designated secure workplace during work hours.
• Strong oral and written communication skills.
• Proficient in Microsoft Office Suite and clinical resources.

Benefits

• Flexible work environment.
• Diverse workplace culture.
• Equal employment opportunities.