Job Description:
• Collaborate with technicians and prior authorization team members to process referrals, answer clinical questions, and collect clinical/medical data for assessments and reviews
• Evaluate and review prior authorization requests and render coverage determinations based on clinical criteria and plan design
• Verify insurance coverage and eligibility, interpret clinical guidelines, consult physicians and healthcare providers, and apply clinical knowledge while following department protocols
• Communicate case decisions promptly to healthcare providers, health plans/employers, patients, and other healthcare professionals
• Handle inbound and outbound calls 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
• Attend training sessions and development meetings
• Provide on-call and after-hours pharmacist availability as needed
• Consult with pharmacy technicians and physicians regarding medication use and recommend formulary alternatives when requested
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 such as Micromedex, Lexicomp, and Clinical Pharmacology
• Ability to prioritize, quickly assess, manage multiple tasks, and adapt to changing situations
• Excellent organizational skills and strong detail orientation
• Strong Microsoft Office skills
• Excellent oral and written communication and interpersonal skills
• Ability to work independently and make clinical decisions
• Experience using MS Office and other Windows-based computer applications
• Ability to receive calls from prior authorization pharmacy technicians and/or providers for clinical information
• Active pharmacist license in good standing in the state of residence
• Bachelor's of Science in Pharmacy or Pharm.D.
• Preferred: PGY1/PGY2
• Preferred: Prior authorization, call center, and clinical experience
• Preferred: Exposure to clinical and analytical problem solving
Benefits:
• CVS Health bonus, commission or short-term incentive program in addition to base pay
• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting colleagues' physical, emotional, and financial well-being
• Comprehensive benefits package for eligible full-time colleagues and their families