Coverage Review Pharmacist

Responsible for various activities associated with coverage reviews and appeals including the review of medication related prior

authorizations, pharmacy appeals, and member grievances focused on medications.

Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations

Responds to prescriber, pharmacy provider, member appeals, grievances and complaints related to the provision of

pharmaceutical services within established time periods

Builds and maintains decision trees in the prior authorization system

Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance

Quals

All applicants will be advised that Client, as a federal contractor, may be required to implement a COVID- vaccine mandate.

Education

l Doctor of Pharmacy (PharmD) Degree

Experience

years - Clinical experience required, and / or completion of year residency and / or board certification

Skills\Certifications

Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.

Competency in compendia navigation and research

Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)

Must be a team player, be organized and have the ability to handle multiple projects

Excellent oral and communication skills

Strong interpersonal and organizational skills

Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required

Knowledge of medical and pharmacy products

License

Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy

EEO :