Clinical Pharmacist – Medicaid Prior Authorization, NC Licensed

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🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $45 - $76 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Evaluate and review prior authorization requests and render coverage determinations based on clinical criteria and plan design • Verify insurance coverage and eligibility and interpret clinical guideline criteria • Consult physicians and other healthcare providers using clinical knowledge and resources while complying with department protocols • Communicate case decisions promptly to healthcare providers, health plans/employers, patients, and other healthcare professionals • Collaborate with technicians and prior authorization team members to process referrals • Answer clinical questions and collect clinical/medical data for assessments and reviews according to agreed criteria and service level agreements • Handle inbound and outbound calls with technicians, team members, physicians, healthcare providers, and patients • Facilitate prior authorization requests, answer inquiries, and resolve escalations • Maintain professional and technical knowledge of drug and disease states for Specialty and Non-Specialty Pharmacy programs • Attend training sessions and development meetings and provide on-call and after-hours pharmacist availability as needed, including weekends

🎯 Requirements

• Must currently hold and maintain an active, unrestricted pharmacist license in good standing in North Carolina • Current experience with prior authorizations within Caremark PBM • Demonstrated experience using clinical resources such as Micromedex, Lexicomp, and Clinical Pharmacology • Prior authorization, call center, and/or clinical pharmacy experience • Strong Microsoft Office skills • Experience using MS Office and other Windows-based computer applications • Ability to prioritize, quickly assess, manage multiple tasks, and adapt to changing situations • Excellent organizational skills and strong attention to detail • Excellent oral and written communication and interpersonal skills • Ability to work independently and make clinical decisions • Ability to receive phone calls from prior authorization pharmacy technicians and/or providers for clinical information • Bachelor's of Science in Pharmacy or Pharm.D. • Preferred: exposure to clinical and analytical problem solving • Preferred: ability to consult with pharmacy technicians and/or physicians regarding medication use and advise on formulary alternatives

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to the base pay range • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility