Clinical Pharmacist 1

Position Title: Clinical Pharmacist 1

Work Location: Remote

Assignment Duration: 3 Months - Possible extension

Work Schedule: 9am - 6pm EST No OT

Pharmacy Ops Dept includes PA and Appeals - Evaluate redetermination and appeals coverage requests

• Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician's recommended denial, suggested formulary alternatives, comments and attachments for appropriateness.
• Verifies member's ID number and date of birth.
• Verifies member's eligibility in the appropriate health plan eligibility system.
• Records carrier and group number if applicable.
• Checks for previous prior authorization decisions.
• Verifies coverage in member's prescription benefit when necessary.
• Verifies coverage in member's health plan benefit when necessary.
• Evaluates prescription claim history.
• Reviews chart notes and/or lab values.
• Identifies provider specialty when appropriate.
• Applies Medical Policy Criteria to prior authorization requests.
• Evaluates whether request meets criteria for approval.
• Reviews the request using professional clinical judgment on a case-by-case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.
• Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool.
• Communicates with physicians regarding prior authorization:
  
  
  
  • For a non-formulary drug
  • Plan benefits, exclusions
  • Quantity limits
  • Age restrictions
  • Formulary alternatives
  
  
  
  
• Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department).
• Compiles data for reporting purposes:
  
  
  
  • Drug utilization of non-formulary drugs
  • Overturned IPS recommended denials
  • Audit pharmacy claims greater than $200.00
  • Suggest addition or deletion of drugs to/from the formulary
  • Updating qty/days or age limit ends
  • Support National P&T Committee
  • Other tasks which may arise during the performance of any of the above-mentioned duties.
  
  
  
  

Qualification & Experience: