Appeals Pharmacist - Remote

Overview

An experienced Appeals Pharmacist is needed to review, evaluate, and process medication coverage appeals, advocating for patients to ensure fair, evidence-based decisions.

In Short

• Review clinical documentation for medication coverage appeals and grievances.
• Apply evidence-based guidelines, plan policies, and regulatory requirements to determine outcomes.
• Prepare written clinical rationales to support appeal determinations.
• Collaborate with physicians, nurses, and medical directors during case reviews.
• Track, document, and report appeal outcomes in compliance with state and federal regulations.
• Support process improvements to enhance timeliness and quality of appeal decisions.

Requirements

• Education: Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy degree.
• Licensure: Active and unrestricted pharmacist license in the U.S.
• Experience: Prior managed care or utilization management experience preferred.
• Skills: Excellent clinical judgment, written communication, and attention to regulatory detail.

Benefits

• Impact: Play a critical role in ensuring patients get fair access to necessary medications.
• Growth: Gain expertise in appeals, utilization management, and managed care pharmacy.
• Flexibility: Many roles offer hybrid or fully remote options.
• Rewards: Competitive salary, comprehensive benefits, and opportunities for advancement.