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Pharmacy Coverage Determination Jobs (NOW HIRING)

Apex Systems

Pharmacist

Solon, OH · On-site

$54.25 - $65/hr

Responsible for reviewing clinical coverage determination and appeals using Medicare and client ... May include Pharmacy, Prescribers, Members, etc. as appropriate 25% 3. Data Entry (Electronic ...

Apex Systems

Pharmacist

Pittsburgh, PA · On-site

$56.50 - $68/hr

Responsible for reviewing clinical coverage determination and appeals using Medicare and client ... May include Pharmacy, Prescribers, Members, etc. as appropriate 25% 3. Data Entry (Electronic ...

Capital Rx

Appeals Pharmacist (temp-to-hire)

Manhattan, NY · Remote

$128K - $160K/yr

Capital Rx , a public benefit corporation delivering full-service pharmacy benefit management (PBM ... Responsible for reviewing clinical coverage determination and appeals for different lines of ...

PacificSource

Clinical Pharmacist Specialist II

Bend, OR · On-site

$125K - $149K/yr

... to Pharmacy Services. * Provide effective communication for members, providers, and internal staff through various platforms such as clinical calls, coverage determination letters, and email.

UnitedHealth Group

Sr. Health Plan Pharmacist

Pearland, TX · On-site

$52 - $62.50/hr

Pharmacy Operations, Clinical Pharmacy Quality Initiatives, Pharmacy oversight and audits and ... Coverage Determination, Direct Member Reimbursement and Redetermination (CDR) Oversight * Ensure ...

PacificSource

Clinical Pharmacist Specialist II

Bend, OR · On-site

$125K - $149K/yr

... to Pharmacy Services. * Provide effective communication for members, providers, and internal staff through various platforms such as clinical calls, coverage determination letters, and email.

UnitedHealth Group

Sr. Health Plan Pharmacist

Pearland, TX · On-site

$52 - $62.50/hr

Pharmacy Operations, Clinical Pharmacy Quality Initiatives, Pharmacy oversight and audits and ... Coverage Determination, Direct Member Reimbursement and Redetermination (CDR) Oversight * Ensure ...

Valeris

Patient Care Associate

Jeffersonville, IN

... and pharmacy benefits plans. * Completion of the template forms that provide patient level benefits Coverage Determination Summary. * Coordination of prior authorizations based on payer guidelines ...

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How much do pharmacy coverage determination jobs pay per hour?

As of Jun 11, 2026, the average hourly pay for pharmacy coverage determination in the United States is $19.27, according to ZipRecruiter salary data. Most workers in this role earn between $16.83 and $20.43 per hour, depending on experience, location, and employer.

What are some common challenges faced in a Pharmacy Coverage Determination role, and how can I prepare for them?

In a Pharmacy Coverage Determination role, professionals often encounter challenges such as interpreting complex insurance policies, staying updated with frequently changing formularies, and managing a high volume of prior authorization requests. Effective communication skills are essential, as you'll regularly interact with healthcare providers, patients, and insurance representatives to clarify coverage decisions. To prepare, it's helpful to familiarize yourself with insurance terminology, develop strong organizational habits, and stay current with relevant regulations and pharmaceutical guidelines.

What are the key skills and qualifications needed to thrive as a Pharmacy Coverage Determination Specialist, and why are they important?

To thrive as a Pharmacy Coverage Determination Specialist, you need a background in pharmacy or healthcare, knowledge of insurance processes, and typically a pharmacy technician certification or relevant experience. Familiarity with pharmacy benefit management (PBM) systems, electronic prior authorization software, and Medicare/Medicaid guidelines is essential. Strong attention to detail, problem-solving skills, and effective communication are critical soft skills for this role. These abilities ensure accurate coverage assessments, compliance with regulations, and positive patient and provider experiences.

What is the difference between Pharmacy Coverage Determination vs Pharmacy Benefits Manager?

AspectPharmacy Coverage DeterminationPharmacy Benefits Manager
RoleDecides whether specific medications are covered under insurance plansManages overall pharmacy benefits, including formulary design and claims processing
CredentialsPharmacists, pharmacy technicians, or healthcare professionalsPharmacists, healthcare administrators, or pharmacy benefit specialists
Work EnvironmentInsurance companies, healthcare providers, or pharmacy benefit departmentsInsurance companies, PBM companies, or healthcare organizations

Pharmacy Coverage Determination focuses on evaluating individual medication coverage requests, while Pharmacy Benefits Managers oversee the broader management of pharmacy benefits, including formulary development and claims processing. Both roles involve pharmacy expertise but differ in scope and responsibilities.

What is a Pharmacy Coverage Determination?

A Pharmacy Coverage Determination is a decision made by a health insurance plan about whether a prescribed medication is covered under a patient's pharmacy benefits. This process typically occurs when a patient or their healthcare provider requests coverage for a drug that is not automatically included on the plan's formulary, or when they seek an exception to standard coverage rules. Coverage determinations can involve approvals for non-formulary drugs, quantity limit exceptions, or prior authorizations. The outcome determines if the insurance will pay for the medication, and patients can appeal unfavorable decisions.
Infographic showing various Pharmacy Coverage Determination job openings in the United States as of June 2026, with employment types broken down into 11% Locum Tenens, 11% As Needed, 72% Full Time, 4% Part Time, and 2% Contract. Highlights an 96% Physical, 1% Hybrid, and 3% Remote job distribution, with an average salary of $40,074 per year, or $19.3 per hour.
Pharmacist

Pharmacist

Apex Systems

Solon, OH • On-site

$54.25 - $65/hr

Contractor

Posted yesterday

Job description

Company Description

Apex Systems LLC, a division of On Assignment, is an IT staffing and services firm specializing in providing IT professionals for contract, contract-to-hire, and direct placements. Apex also offers recruitment solutions for other select professional skills and workforce needs

Job Description

Position Summary: Responsible for reviewing clinical coverage determination and appeals using Medicare and client specific requirements. Knowledgeable in all aspects of coverage determination and appeals process and assist in meeting clients expectations regarding efficiency, services levels, privacy maintenance and quality decision making. Work as part of the team to meet business unit objectives. The Pharmacist will be responsible for reviewing medication exception request, as well as completing data analysis and various clinical projects. Escalate issues to Coverage Determinations and Appeals management team as needed. Position will require schedule flexibility including rotations through nights, weekend and holiday coverage. All other duties are required to meet business needs.


Duties: Responsibilities :

1. Review the information provided upon request by utilizing the designated tools (web based) for further research. High proficiency in computer skills is necessary including but not limited to Microsoft Word, Microsoft Excel, and web based programs. 60% 

2. Outreach for additional information. May include Pharmacy, Prescribers, Members, etc. as appropriate 25% 

3. Data Entry (Electronic Database) recording decision making, inputting clinical notation, request for additional information, faxes, summary, etc. 10% 

4. Training - attending meetings, online job aides, process changes, new initiatives, communication, etc. both formal and informal training 5%


Qualifications

Experience: REQUIRED SKILLS: 

1. Self-motivated with a strong attention to detail 

2. Excellent verbal and written communication and interpersonal skills w/ ability to maintain patient confidentiality 

3. Strong clinical decision making skills 

4. Customer Service internally and externally 

5. Proficient computer skills and the ability to navigate in a Windows based environment 

6. Ability to follow directions, and adapt in dynamic work environment; ability to adapt to change and remain flexible 

7. Adaption to Change Management 

8. Ability to work in a high pressure, time sensitive environment 

9. Project a professional business image, through phone interaction as well as internal communications 10. Demonstrates resourcefulness in problem-solving 

11. Demonstrates a sense of urgency with assignments 

12. Strong organizational skills 

13. Able to prioritize and manage multiple tasks 

14. Ability to read, analyze and interpret general business correspondence, technical procedures and governmental regulations. 

15. Ability to identify and solve practical problems and deal with a variety of concrete variables in standardized situations. Ability to perform basic mathematic calculations maybe required 

16. Ability to interpret a variety of work instructions provided through a variety of mediums 

17. Ability to consistently meet quality and production standards 

18. Displays confidence in the ability to learn complex material 

19. Demonstrates intellectual curiosity through inquiries to ensure deep understanding of the business and deliver accurate results 2 years experience required, 2-5 years experience preferred.


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