Coverage Review Pharmacist

Job Duties & Responsibilities

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

Serves as a clinical resource to aid in solving basic to mid-level reviews with limited assistance and supervision.

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

Participates in alternating team on-call rotation.

Job Qualifications

• Education: Doctor of Pharmacy (PharmD) Degree
• Experience: 3 years - Clinical experience required, and/or completion of 1 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).

Other Requirements

• Must be a team player, be organized and able to handle multiple projects.
• Excellent oral and written communication skills.
• Strong interpersonal and organizational skills.
• Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required.
• Knowledge of medical and pharmacy products.

Licenses

• Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy within 120 days of employment.

Number of Openings

1

Worker Type

Employee

Company

BCBST BlueCross BlueShield of Tennessee, Inc.