Clinical Coverage Determination Specialist
23 hours ago
As a Clinical Coverage Determination Specialist at Capital Rx, you will be responsible for reviewing clinical coverage determinations and appeals for various lines of business, including Commercial and Medicare. You will utilize your knowledge of coverage determination and appeals processes to meet client expectations regarding efficiency and quality decision-making.
Key Responsibilities:
Evaluate and review 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 health plan criteria.
Interpret clinical guideline criteria and utilize clinical knowledge and resources to render 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.
Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast-paced, structured environment within established time frames.
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).
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New York, New York, United States Capital Rx Full timeJob SummaryWe 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 ResponsibilitiesEvaluate and review all appeals requests to render...
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