Remote - Clinical Pharmacist

Location: Remote NC. Duration: 6 months.

Responsibilities

• Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria
• Report to utilization review statistics to corporate compliance committees
• Review data and summarize daily utilization review numbers
• Responsible for tracking compliance of review cases
• Provide clinical guidance and support to the assigned pharmacy technicians
• Knowledge of drug coding (NDC, GCN, GPI and USC) and NCPDP claims adjudication systems
• Review guideline criteria for prior authorization and non-formulary drugs in support of Pharmacy and Therapeutics Committee function and pharmacy benefit design.
• Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practices
• Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews

Requirements

• Bachelor's degree or advanced degree
• 3+ years of experience in related field.
• Current state's pharmacy license.

Preferred Qualifications

• License & Credentials: Holds active North Carolina pharmacist license
• Professional Background: Retail pharmacy experience with strong insurance knowledge, Prior Authorization review experience, PBM (Pharmacy Benefit Manager) background, and managed care experience
• Technical Skills: MHK RX claims processing and Prime Therapeutics systems familiarity
• Industry Experience: Rotation as pharmacy student at health plan/managed care organizations and previous contractor role experience
• Strengths: Team player with collaborative approach, strong understanding of retail pharmacy operations and insurance processes, skilled in reviewing and processing prior authorizations