Job Title : Clinical Pharmacist
Duration : 3 Months
Location : REMOTE
Responsibilities :
- Reviews a completed prior authorization request received from the provider and / or reviews the pharmacy technician's recommended denial, suggested formulary alternatives, comments and attachments for appropriateness.
- Verifies member's ID number and date of birth.
- Verifies member's eligibility in the appropriate health plan eligibility system.
- Records carrier and group number if applicable.
- Checks for previous prior authorization decisions.
- Verifies coverage in member's prescription benefit when necessary.
- Verifies coverage in member's health plan benefit when necessary.
- Evaluates prescription claim history.
- Reviews chart notes and / or lab values.
- Identifies provider specialty when appropriate.
- Applies Medical Policy Criteria to prior authorization requests.
- Evaluates whether request meets criteria for approval.
- Reviews the request using professional clinical judgment on a case by case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.
- Researches and contributes drug references and clinical information to facilitate prior authorization review : directly to physicians via fax or phone encounter;
or to pharmacy technicians via memo or on a personal level as an educational tool
Communicates with physicians regarding prior authorization :
o For a non-formulary drug
o Plan benefits, exclusions
o Quantity limits
o Age restrictions
o Formulary alternatives
- Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department)
- Compiles data for reporting purposes :
o Drug utilization of non-formulary drugs
o Overturned IPS recommended denials
o Audit pharmacy claims greater than $200.00
o Suggest addition or deletion of drugs to / from the formulary
o Updating qty / days or age limit ends
o Support National P&T Committee
o Other tasks which may arise during the performance of any of the above mentioned duties
Required Skills / Experience :
Preferred Skills / Experience :
Pharmacy Experience (any setting)
Education Requirement :
Pharm D
Education Preferred :
Software Skills Required :
Office Suite
Required Certifications :
n / a
Required Testing : n / a
n / a
Note : The Company is committed to complying with the California Privacy Rights Act ("CPRA") effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees.
A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website . Applicants with disabilities may access this notice in an alternative format by contacting NAhr@spectraforce.com .
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