Remote Prior Authorization Jobs in Hamilton, OH (NOW HIRING)

Position Summary The Clinical Pharmacist - AMA Dual will be a multi-dimensional position; the primary areas of responsibility will include the following: Complete Clinical Reviews and provide a determination of Medicare-Medicaid Coverage Determination/Redetermination, Medical Review, Global Exception etc. by reviewing all requests which are not clearly approvable based on specified criteria (algorithms). Responsible for support and input to clinical programs such as: Health Management (IDT), Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high quality, cost effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place.

Continually monitor the quality and efficiency of the Prior Authorization process including coverage criteria, denial language, and communication with prescribers and members. Provide recommendations to physicians to improve medication regimens as appropriate. Provide input to clinical content of new programs and for maintenance of existing programs.

Complete all annual NCQA, Aetna required and Quarterly IRR training requirements. Responsible for supporting / providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee. Assists Member Services and other internal customers in responding to and resolving pharmacy-related inquiries from members (NCQA Requirement).

Maintain open lines of communication with other functional areas/departments. Responsible for staying current with clinical literature and guidelines and relaying those to the program development core teams. Remote role open to qualified candidates within the United States.

Team hours are M-F, 6:30am-6pm AZ time. Colleague will be scheduled a regular shift during this timeframe once training is complete. On-call or weekend hours may be required post-training to meet business needs, current rotation requirement is every 5th weekend.

Required Qualifications Demonstrated proficiency in Microsoft Excel, Word, Outlook, and SharePoint Superior written and verbal communication skills 1+ year managed care pharmacist experience (Medicaid and/or Medicare) and/or completion of PGY1 managed care residency 1+ year of previous clinical pharmacy experience Demonstrated knowledge of clinical program components, formulary designs, and prescription benefit trends Active Registered Pharmacist license is required in State of Residence Preferred Qualifications 3+ years of experience working as a licensed Pharmacist 3+ years managed care experience is highly desirable, but not required RxClaim experience Proven success in a fast‐paced, remote working environment Education Doctor of Pharmacy degree (Pharm.D.) Anticipated Weekly Hours 40 Time Type Full time Pay Range $106,200.00 - $225,000.00 The typical pay range for this role is: $106,200.00 - $225,000.00. This pay range represents the base hourly rate or base annual full‐time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

This position is eligible for a CVS Health bonus, commission or short‐term incentive program in addition to the base pay range listed above. Benefits This full‐time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‐being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr