Clinical Pharmacist Advisor - Med D Prior Auth

Job Description :

As an RPh Advisor you will be directly supporting Medicare Part D members and providers with requests related to their pharmacy benefits.

Responsible for ensuring cases are accurately set up for our members, review clinical information for decisioning the request, performing outreach to providers for more information when needed, and ensuring accurate decisions that comply with compendia and Medicare guidance and timelines.

Reviewing information and completing timely and accurate documentation of all Medicare Part D requests, in compliance with Medicare guidelines, while promoting a best-in-class service experience.

Responsibilities :

Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design.

Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols.

One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans / employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes. (%)

Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical / medical data needed to perform clinical assessments and reviews as per the health plan / employer-agreed criteria within the designated service level agreements.

Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and / or patients to facilitate prior authorization requests, answer inquiries, and / or resolve escalations. (%)

• Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of busines. (%)
• Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed. (%)

Experience :

Knowledge of Access, Power Point, and Visio is preferable.

Must be computer literate knowledge of Excel and Word.

Licensed Registered Pharmacist in state of residence

Minimum year of experience although - years is preferred

Skills : Medicare Part D

Medicare Part D

Prior Authorization

Knowledge of Access, Power Point, and Visio.

Education :

Bachelor's degree in pharmacy or Pharm D. required, with at least one year experience as a pharmacist. Must have an active license in good standing

About US Tech Solutions :

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.

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US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.