Title: Pharmacist 1
Location: Remote
Duration: 3 months
Schedule: 9am 6pm EST No OT
Typical role in a day:
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 XX200.00
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
Education/Certification:
Pharm D.
Licensure
FL Pharmacist license
Must haves:
At least one year of professional RPh experience
Nice to haves:
Some experience working in managed care, understanding of Medicare/Medicaid law
Top 3 must-have hard skills
Self-Motivated/Good Time Management Skills
Working Knowledge of Office Suite
Goal Oriented
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