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Pharmacist - Medicare Clinical Appeals

3 months ago

Mason, United States Elevance Health Full time

Please note: This is a virtual role where the successful hire will be located within 50 miles of a company office (PulsePoint) and may get asked to attend a town hall office meeting once a quarter.

Position specific details: The successful candidate will have experience with Medicare appeals and/or utilization review experience.

The Pharmacist - Medicare Clinical Appeals is responsible for managing the selection and utilization of pharmaceuticals and supports core clinical programs such as DUR.

Primary duties may include, but are not limited to:

  • Researches and synthesizes detailed clinical data related to pharmaceuticals.

  • May review and approve or deny coverage for pharmaceuticals (as permitted by state/federal law or state/federal program contracts) based on medical necessity criteria, and coordinates with Elevance Health or health plan medical directors as needed.

  • Serves as a clinical resource to other pharmacists on areas such as prospective and retrospective DURs and provides dosage conversion and clinical support for therapeutic interventions.

  • Prepares information for network physicians.

Position requirements

  • Requires BA/BS in Pharmacy.

  • Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background.

  • Requires a registered pharmacist.

  • Must possess an active unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh). PharmD preferred.

  • Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US, unless they are command-sanctioned activities.

  • For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Preferred qualifications

  • Utilization management/review experience is strongly preferred.

  • Experience with Medicare is a plus.

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $112,000 to $201,600

Locations: Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .

  • The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.