Clinical Pharmacist - Prior Authorization

About the role

This is a remote Clinical Pharmacist position within the Prior Authorization team at CVS Health. You will collaborate with technicians and team members to process referrals, answer clinical questions, and collect necessary clinical/medical data to perform assessments and reviews based on health plan and employer-agreed criteria within designated service level agreements.

Responsibilities

• Evaluate and review prior authorization requests, rendering coverage determinations based on clinical criteria and plan design.
• Verify insurance coverage and eligibility, interpret clinical guideline criteria, consult physicians and other healthcare providers, and utilize clinical knowledge while complying with department protocols.
• Ensure timely and efficient communication of case decisions to healthcare providers, health plans/employers, patients, and other healthcare professionals following approval and denial management processes.
• Handle inbound and outbound phone calls with technicians, team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and resolve escalations.
• Establish and maintain communication among CVS Caremark, health plan, and employer group staff.
• Maintain professional and technical knowledge of drug and disease states for Specialty and Non-Specialty Pharmacy programs within the Commercial Prior Authorization and Case Review Unit (CRU).
• Perform other related projects and duties as assigned, including attending training sessions, development meetings, and providing on-call and after-hours pharmacist availability as needed.

Requirements

• 2 years’ experience working as a pharmacist in a PBM setting.
• Current experience working with commercial Prior Authorizations within Caremark PBM.
• Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology.
• Ability to prioritize, quickly assess, manage multiple tasks, and adapt to constantly changing situations.
• Excellent organizational skills and strong detail orientation.
• Strong Microsoft Office skills.
• Excellent oral and written communication skills and interpersonal skills.
• Ability to work independently and make clinical decisions.
• Experience using MS Office and other Windows-based computer applications.
• Ability to receive phone calls from prior authorization pharmacy technicians and/or providers for clinical information.
• Active pharmacist license in good standing in the state of residence.

Preferred Qualifications

• PGY1/PGY2 residency experience.
• Prior authorization, call center, and clinical experience.
• Exposure to clinical and analytical problem solving.
• Ability to consult with pharmacy technicians and/or physicians regarding medication use and advise on appropriate formulary alternatives when requested.

Qualifications

Bachelor's of Science in Pharmacy or Pharm.D.

Schedule

Full-time, 40 hours per week.

Pay

The typical pay range for this role is $50.48 - $84.62 per hour. This position is also eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range.

Benefits

This full-time position is eligible for a comprehensive benefits package, including:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources.