Licensed Appeals Pharmacist

Job Summary

Evaluating clinical coverage determinations and appeals, the remote Licensed Appeals Pharmacist will review appeal requests, collaborate with medical directors, and make clinical prior authorization decisions while maintaining quality and productivity standards.

Key responsibilities

• Evaluate and review appeals requests to render coverage determinations based on clinical criteria and medical necessity
• Collaborate with internal and external Medical Directors by providing necessary clinical data for reviews
• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines

Required qualifications

• Active, unrestricted pharmacist license required
• 1+ years prior authorization review or appeals experience required
• Ability to work independently in a remote, high-volume environment
• Designated secure workplace free from disruptions during work hours
• Proficient in Microsoft Office Suite and experience with clinical resources