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Pharmacist Clinical Reviewer
2 months ago
Job Summary:
SmithRx is a rapidly growing Health-Tech company dedicated to transforming the Pharmacy Benefit Management (PBM) sector. We're seeking a skilled Clinical Review Pharmacist to join our clinical services team and contribute to optimizing our clinical offerings and outcomes for customers, members, and clients.
Key Responsibilities:
- Complete prior authorization reviews for all lines of businesses and all edit types
- Respond to escalations from other internal departments
- Apply clinical judgment to evaluate member clinical situations against medication policies and plan benefit design to make coverage determinations for approval or denial, including identification of covered alternatives
- Organize and prioritize multiple requests internally and externally to ensure timely prior authorization case management
- Build and adjust authorizations under protocol within the claim adjudication system
- Triage, assess, and respond to pharmacy technicians, member support, account management, benefit/plan operations, and document management specialist inquiries regarding claims processing and prior authorization requests
- Maintain open lines of communication with other functional areas within SmithRx
- Provide effective communication of SmithRx's vision, mission, values, and goals
Requirements:
- Bachelor's Degree in Pharmacy or PharmD required
- 2-5 years pharmacy experience
- Clear, active pharmacist license
- Preferred: 1 year experience with prior authorizations for commercial plans
- Strong clinical skills with the ability to apply sound clinical judgment to a variety of complex situations
- Proficiency in drug literature and clinical trial evaluation, including electronic databases such as Micromedex, Medline, and UptoDate
- Emphasis on problem-solving skills, including identifying and accepting a challenging situation and proposing a solution
- Proficiency in MS Word, Excel, and Powerpoint, including tables, charts, and figures preferred
