Clinical Pharmacist - Prior Authorization

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

About the role

This position is for a Clinical Pharmacist working in the Prior Authorization team. 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.

Responsibilities

• Evaluate and review all prior authorization requests and render 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 appropriately utilize clinical knowledge and resources while complying with department protocols.
• Guarantee that decisions regarding cases are conveyed promptly and efficiently to all healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes.
• Perform and handle 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.
• Establish and maintain communication among CVS Caremark, health plan, and employer group staff.
• Maintain 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 business.
• Perform 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.

This is a remote role open to candidates within the United States.

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 that is in good standing in the state of residence.

Qualifications

• Bachelor's of Science - Pharmacy or Pharm.D.

Preferred Qualifications

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

Schedule

• Anticipated Weekly Hours: 40
• Time Type: Full time

Pay

The typical pay range for this role is $45.43 - $76.15 per hour. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Benefits

This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include:

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