Pharmacist for Clinical Coverage Determination

4 days ago


New York, New York, United States Capital Rx Full time
Job Summary

We are seeking a highly skilled Pharmacist to join our team as a Clinical Coverage Determination Specialist. In this role, you will be responsible for reviewing clinical coverage determinations and appeals for different lines of business, including Commercial and Medicare.

Key Responsibilities
  • Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity.
  • Collaborate with internal and external Medical Directors to provide clinical/medical data needed to perform clinical reviews per the health plan criteria.
  • Interpret clinical guideline criteria and utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals.
  • Perform peer to peer reviews with providers when requested.
  • Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides.
  • Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times.
  • Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
Requirements
  • Active, unrestricted, pharmacist license required.
  • 1+ years prior authorization review or appeals experience required.
  • Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric-driven environment with shifting priorities.
  • Strong oral and written communication skills required.
  • Proficient in Microsoft Office Suite and experience using clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology).
About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation's electronic healthcare infrastructure to improve drug price visibility and patient outcomes.

We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.



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