Summary:
Work Mode: 100% Remote
Shift: 9am – 6pm EST, No OT
Duration: 3 months
Responsibilities:
- Review completed prior authorization requests from providers and pharmacy technicians' recommendations.
- Verify member’s ID number, date of birth, and eligibility in the appropriate health plan system.
- Record carrier and group number if applicable.
- Check for previous prior authorization decisions and verify coverage in member’s prescription and health plan benefits when necessary.
- Evaluate prescription claim history and review chart notes and/or lab values.
- Identify provider specialty when appropriate and apply Medical Policy Criteria to requests.
- Evaluate whether requests meet criteria for approval using professional clinical judgment.
- Research and contribute drug references and clinical information to facilitate prior authorization review.
- Communicate with physicians regarding non-formulary drugs, plan benefits, exclusions, quantity limits, age restrictions, and formulary alternatives.
- Retrieve and collect data through available reporting resources and compile data for reporting purposes.
Requirements:
- Pharm D. required
- Must have at least one year of professional RPh experience
- Licensure in any US state required
- Self-motivated and metric-driven
- Easily adaptable to frequent change
- Minimal gaps in employment history
Preferred Skills:
- Experience with systems such as MHK, Micromedex, AHFS
- Some experience working in managed care
- Understanding of Medicare/Medicaid law
- Licensure in states such as WA, GA, FL, IN, NC, and NH could be a plus
Performance Indicators:
- Sign 85 – 100 cases daily