Remote Pharmacist
Description
Candidates will be reviewing members’ Utilization Management (UM) requests (i.e., formulary exceptions, prior authorization, step therapy, quantity limit exceptions). Client-specific criteria are referenced to determine if a prior authorization can be approved or denied. The work is detail-oriented, and candidates will be expected to provide clinical judgement and communication.
• Responsible for the clinical evaluation for coverage determination requests for PA or other UM programs, including quantity limits, step therapy, formulary exception and tier exception, and includes consideration of the denial language and appropriateness of the decision as it pertains to the clinical content of the case and the intent of the individual client’s pre-approved criteria
• Accountable for direct consultation with health care providers or members concerning non-formulary and clinical product coverage issues
• Collaborate with team members to promote con...