Job Description

Job Responsibilities:

• Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols. One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes.
• Collaborate 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. Performs and handles bound 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.
• 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.

Skills:

• Pharmacist,
• Insurance,
• Prior Authorization

Education/Experience:

• Bachelor of Science - Pharmacy or Pharm.D.
• Remote must be licensed in the state of North Carolina. (Can reside in any state)

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