Position Summary: 

Responsible for reviewing clinical coverage determination and appeals for different lines of business such as Commercial and Medicare. Knowledgeable in all aspects of coverage determination and appeals process and assist in meeting client expectations regarding efficiency and quality decision making. 

Position Responsibilities:  

• Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity. Performs and handles inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations. 

• Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria. 

• Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals. 

• Perform peer to peer reviews with providers when requested. 

• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers. 

• Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides. 

• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times. 

• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements. 

• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities. 

• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies. 

• Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frames. 

• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance. 

Minimum Qualifications: 

• Active, unrestricted, pharmacist license required 

• 1+ years prior authorization review or appeals experience required 

• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities 

• Have a designated workplace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations 

• Strong oral and written communication skills required 
• Proficient in Microsoft Office Suite and experience using clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology) 

Preferred Qualifications:

• Experience working with Medicare appeals preferred