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/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 professionals following approval and denial management processes.
• Handle inbound and outbound calls with technicians, team members, physicians, healthcare providers, and 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 in 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 and experience using other Windows-based computer applications.
• Excellent oral and written communication skills and interpersonal skills.
• Ability to work independently and make clinical decisions.
• 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.

Education

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

Schedule

• Full-time position.
• 40 anticipated weekly hours.

Pay

The typical pay range for this role is $45.43 - $76.15 per hour. This range represents the base hourly rate for all positions in the job grade. The actual base salary offer will depend on factors including experience, education, geography, and other relevant considerations. 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.

Additional details about available benefits are provided during the application process and on Benefits Moments.