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Appeals Pharmacist
3 weeks ago
A confidential managed care organization is seeking an experienced Appeals Pharmacist to review, evaluate, and process medication coverage appeals. This role is ideal for pharmacists who want to leverage their clinical knowledge and critical thinking skills to advocate for patients and ensure fair, evidence-based decisions.
Key Responsibilities
- Review clinical documentation for medication coverage appeals and grievances.
- Apply evidence-based guidelines, plan policies, and regulatory requirements to determine outcomes.
- Prepare written clinical rationales to support appeal determinations.
- Collaborate with physicians, nurses, and medical directors during case reviews.
- Track, document, and report appeal outcomes in compliance with state and federal regulations.
- Support process improvements to enhance timeliness and quality of appeal decisions.
- Education: Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy degree.
- Licensure: Active and unrestricted pharmacist license in the U.S.
- Experience: Prior managed care or utilization management experience preferred - retail and hospital pharmacists with strong clinical and documentation skills are encouraged to apply.
- Skills: Excellent clinical judgment, written communication, and attention to regulatory detail.
- Impact: Play a critical role in ensuring patients get fair access to necessary medications.
- Growth: Gain expertise in appeals, utilization management, and managed care pharmacy.
- Flexibility: Many roles offer hybrid or fully remote options.
- Rewards: Competitive salary, comprehensive benefits, and opportunities for advancement.
About Us
We are a confidential healthcare partner working with health plans and managed care organizations nationwide. Our appeals pharmacists safeguard patient access while ensuring compliance with all regulatory standards.
Apply Today
Join our team as an Appeals Pharmacist and help ensure every patient receives a fair review of their medication needs.
