Pharmacist Coverage Review Specialist

4 days ago

Chattanooga, Tennessee, United States BlueCross BlueShield of Tennessee Full time
Job Summary

BlueCross BlueShield of Tennessee is seeking a highly skilled Pharmacist to join our team as a Coverage Review Pharmacist. As a key member of our team, you will be responsible for performing prospective and retrospective coverage reviews and appeals, ensuring compliance with State and Federal regulations. You will also serve as a clinical resource and drug information specialist to other healthcare providers, building and maintaining decision trees in our prior authorization system. Additionally, you will maintain denial rationale associated with clinical criteria and ensure that decision letters meet regulatory compliance. This is a challenging and rewarding role that requires strong clinical knowledge, excellent communication skills, and the ability to work independently with minimal supervision. If you are a motivated and detail-oriented Pharmacist looking for a new opportunity, we encourage you to apply.

Responsibilities

  • Perform prospective and retrospective coverage reviews and appeals per State and Federal regulations
  • Serve as a clinical resource and drug information specialist to other healthcare providers internally, as needed
  • Build and maintain decision trees in the prior authorization system
  • Maintain denial rationale associated with clinical criteria and ensure that decision letters meet regulatory compliance
  • Participate in alternating team on-call rotation


Requirements

  • Doctor of Pharmacy (PharmD) Degree
  • 3 years - Clinical experience required, and/or completion of 1 year residency and/or board certification


Preferred Qualifications

  • 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 able to handle multiple projects
  • Excellent oral and written 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 within 120 days of employment


Equal Employment Opportunity

BlueCross BlueShield of Tennessee is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. We will take affirmative action to recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Tobacco-Free Hiring Statement

To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test. An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine and/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results. Resources to help individuals discontinue the use of tobacco/nicotine products include https://www.cdc.gov/tobacco/index.htm or 1-800-QUIT-NOW.

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