Coverage Review Pharmacist

Job Title: Pharmacist Coverage Reviews and Appeals

Duration: 5 Months
Location: Tennessee (Licensed or Eligible for Licensure)
Type: Contract / Full-time

Responsible for various activities associated with coverage reviews and appeals including the review of medication related prior
authorizations, pharmacy appeals, and member grievances focused on medications.

Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations
Responds to prescriber, pharmacy provider, member appeals, grievances and complaints related to the provision of
pharmaceutical services within established time periods
l
l Builds and maintains decision trees in the prior authorization system
l Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance

Quals--
All applicants will be advised that Client, as a federal contractor, may be required to implement a COVID-19 vaccine mandate.

Education
l Doctor of Pharmacy (PharmD) Degree

Experience
3 years - Clinical experience required, and/or completion of 1 year residency and/or board certification

Skills\Certifications
Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.

Competency in compendia navigation and research
Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)
Must be a team player, be organized and have the ability to handle multiple projects
Excellent oral and communication skills
Strong interpersonal and organizational skills
Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required
Knowledge of medical and pharmacy products

License
Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy