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Coverage Determination Jobs (NOW HIRING)

Talent Software Services

Pharmacist (R)

Philadelphia, PA · On-site

$58.75 - $70.75/hr

No experience required, Prior Authorization or Coverage Determination experience preferred * Proficient PC skills in a Windows-based environment Education: * Bachelor's Degree, PharmD preferred

A-Line Staffing Solutions

Be Seen First

Remote Pharmacist - Prior Authorization / PBM Experience

Phoenix, AZ · Remote

$53 - $55/hr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

Review and evaluate prior authorization and coverage determination requests. * Interpret Medicare Part D guidelines, formulary requirements, and clinical criteria. * Apply evidence-based clinical ...

eTeam

Pharmacy Specialist Level 1

$21 - $27/hr

Submit for clinical review and determination. * Directly interact with members, physician office staff, pharmacies and internal stakeholders for eligibility, coverage determination, and claims issues.

ARC Group

Medical Research Consultant

Jacksonville, FL · Remote

... Coverage Determination (LCD) or other action by the Medical Policy team. Medical Research Consultants are responsible for conducting comprehensive literature searches and reviews to support evidence ...

Jobtailor

Vice President - Patient Access

Columbus, OH · On-site

$150 - $210/hr

Experience in benefits verification, coverage determination, and reimbursement analysis for specialty medications (Required) * Experience with complex manufacturer‑restricted access models ...

UnitedHealthcare

Health Plan Clinical Pharmacist

Pearland, TX · On-site

$105K - $126K/yr

  • Medical

  • Retirement

Review medical information essential for coverage determination to be conducted. Properly enters data into software program(s). Enter overrides in appropriate systems to process payment. Generates ...

Reliant Medical Group

Health Plan Clinical Pharmacist

Pearland, TX · On-site

$105K - $126K/yr

  • Medical

  • Retirement

Review medical information essential for coverage determination to be conducted. Properly enters data into software program(s). Enter overrides in appropriate systems to process payment. Generates ...

UnitedHealth Group

Health Plan Clinical Pharmacist

Pearland, TX

$105K - $126K/yr

  • Medical

  • Retirement

Review medical information essential for coverage determination to be conducted. Properly enters data into software program(s). Enter overrides in appropriate systems to process payment. Generates ...

UMR

Health Plan Clinical Pharmacist

Pearland, TX · On-site

$105K - $126K/yr

  • Medical

  • Retirement

Review medical information essential for coverage determination to be conducted. Properly enters data into software program(s). Enter overrides in appropriate systems to process payment. Generates ...

divvyDOSE

Health Plan Clinical Pharmacist

Pearland, TX · On-site

$105K - $126K/yr

  • Medical

  • Retirement

Review medical information essential for coverage determination to be conducted. Properly enters data into software program(s). Enter overrides in appropriate systems to process payment. Generates ...

UnitedHealth Group

Health Plan Clinical Pharmacist

Pearland, TX · On-site

$105K - $126K/yr

  • Medical

  • Retirement

Review medical information essential for coverage determination to be conducted. Properly enters data into software program(s). Enter overrides in appropriate systems to process payment. Generates ...

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Showing results 41-60

All JobsCoverage Determination Jobs

Coverage Determination information

See salary details

$54.5K

$96.2K

$139K

How much do coverage determination jobs pay per year?

As of Aug 18, 2026, the average yearly pay for coverage determination in the United States is $96,169.00, according to ZipRecruiter salary data. Most workers in this role earn between $81,000.00 and $109,500.00 per year, depending on experience, location, and employer.

What is a coverage determination?

A Coverage Determination is a decision made by a health insurance company, usually Medicare Part D or Medicare Advantage plans, regarding whether a specific prescription drug or service will be covered for a member. Members or their healthcare providers can request a coverage determination if they need a medication that is not typically covered, or if they need an exception to the plan's rules. The process involves reviewing the member's medical necessity and the plan's formulary guidelines before issuing an approval or denial.

What are the key skills and qualifications needed to thrive as a coverage determination specialist, and why are they important?

To thrive as a Coverage Determination Specialist, you need a solid understanding of insurance policies, pharmacy benefit management, and medical terminology, often supported by a relevant degree or healthcare experience. Familiarity with claims processing software, Medicare Part D systems, and regulatory guidelines is essential. Strong attention to detail, analytical thinking, and effective communication skills help in reviewing requests and coordinating with healthcare providers. These skills ensure accurate and timely coverage decisions, improving patient care and maintaining compliance with industry standards.

What are some typical challenges faced in a coverage determination role, and how can they be managed effectively?

Professionals in Coverage Determination often encounter challenges such as navigating complex insurance policies, ensuring compliance with regulations, and balancing timely responses with thorough case reviews. Staying up-to-date on changing healthcare laws and payer requirements is crucial, as is maintaining clear communication with providers, members, and team members. Developing strong organizational skills and leveraging available technology can help manage workloads efficiently and ensure accurate determinations.

What is the difference between Coverage Determination vs Claims Processor?

AspectCoverage DeterminationClaims Processor
Required credentialsTypically requires healthcare or insurance-related certificationsOften requires administrative or clerical experience
Work environmentHealthcare insurance companies, government agenciesInsurance companies, healthcare providers, third-party administrators
Employer and industry usageUsed in health insurance to decide coverage eligibilityUsed to process and review insurance claims for payment

Coverage Determination involves evaluating whether a healthcare service or item is covered under an insurance policy, often requiring detailed review of medical necessity and policy terms. Claims Processors handle the administrative task of reviewing submitted claims, ensuring accuracy, and facilitating payment. While both roles are integral to insurance operations, Coverage Determination focuses on eligibility, whereas Claims Processors manage claim processing and reimbursement.

More about Coverage Determination jobs

What job categories do people searching Coverage Determination jobs look for?

The top searched job categories for Coverage Determination jobs are:

Coverage Determination jobs near you
Infographic showing various Coverage Determination job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 84% Full Time, 10% Part Time, and 5% Contract. Highlights an 79% Physical, 1% Hybrid, and 20% Remote job distribution, with an average salary of $96,169 per year, or $46.2 per hour.

Pharmacist (R)

Talent Software Services

Philadelphia, PA • On-site

$58.75 - $70.75/hr

Other

Posted 11 days ago

Job description

Duties:

  • As a licensed healthcare professional employed in the Prior Authorization Department, the primary responsibility is to make determinations on prior authorization requests for coverage of pharmaceutical products.
  • Determinations include medical necessity and benefit decisions.
  • Decisions are made in accordance with established pharmacy guidelines, prior authorization criteria, industry regulations, and sound clinical judgment.
  • Works independently with respect to reviews and decision-making, with the support of Pharmacist II (R)s and supervisors.
  • Works as a member of a team of peers committed to meeting or exceeding quality standards and customer performance guarantees.
  • This position includes a rotating weekend schedule if business needs dictate.
Additional responsibilities include:
  • Provide clinical support to the Customer Care Center
  • Engage providers in discussions to support determinations
  • Support Fraud and Abuse program oversight
  • Keep abreast of industry trends and regulatory changes
  • Keep abreast of operational directives and customer reference materials
Skills:
  • No experience required, Prior Authorization or Coverage Determination experience preferred
  • Proficient PC skills in a Windows-based environment
Education:
  • Bachelor's Degree, PharmD preferred
  • Current Pharmacist license

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