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Coverage Determination Pharmacist - Remote

Pharmpix 00968, PR

  • Expired: over a month ago. Applications are no longer accepted.
Job Description

This is your chance to unleash your full potential!


PharmPix, is currently seeking for qualified Coverage Determination Pharmacist candidate to join our team. We are looking for successful people like you. Join the fastest growing Pharmacy Benefit Management (PBM) company in its category and take your professional career to the next level. PharmPix has become a leading provider of pharmacy benefit solutions and services in the continental United States and the territories.


Our work philosophy is based on commitment, dedication and loyalty. We take care of our employees, just as we ensure the welfare of our clients and partners. If you are creative, service oriented, resourceful and visionary, we would like to hear from you.


Position Summary

The Coverage Determinations Pharmacist reports to the Clinical Manager. The Coverage Determinations Pharmacist will review, evaluate, communicate, document, track, and make determinations within the protocol for pharmacy benefit coverage determination requests such as requests for formulary exceptions, prior authorization (PA), step therapy (ST), and quantity limit (QL) exceptions, and override processes for formulary exceptions (e.g. product service not covered (PSNC)) and delegated utilization management (UM) products and services based upon regulation and defined procedures. The Coverage Determination Pharmacist will review and evaluate coverage determination requests for the clinical opportunity to address the appropriateness of therapy, clinical interventions, generic substitution, or therapeutic interchange opportunities with potential cost savings outcomes, and/or interventions. This individual will assist with efforts to initiate, support, and continue cost-effective, rational drug and disease therapy, utilizing distinct but inter-related clinical management and cross-departmental functions that focus on improving the health of members while reducing overall health care costs.


Essential Roles and Responsibilities


  • Evaluate formulary utilization management program (Prior Authorization (PA), Step Therapy (ST), Quantity Limit (QL), Product Service Not Covered (PSNC), and drug utilization review (DUR), including concurrent, prospective, and retrospective DUR, such as Drug-Drug Interaction, Dose Check, Drug-Pregnancy Precaution, Drug-Age Precaution, Drug-Gender Precaution, Duplicate Therapy, and Drug-Disease Interaction) alerts.
  • Perform coverage determinations on drug coverage by reviewing and analyzing requests for prescription drugs; relay denial or approval to the requester following verification of member benefits, medical diagnosis, and review of information regarding the requested prescription drug. 
  • Manage and be the subject matter expert of the coverage determination and PA processes and protocols by updating and creating program criteria, policies and procedures, and functional operation to ensure program success and program goal achievement of enhanced therapeutic outcomes for targeted plan beneficiaries through improved medication use. 
  • Responsible for interfacing with physicians, pharmacists, and pharmacy providers concerning members’ benefits and therapeutic interventions and reviewing/evaluating the coverage determination requests and utilization data for program management and development. 
  • Responsible for the protocol development, maintenance, and administration of prior authorization programs and medical necessity reviews. 
  • Responsible for processing prior authorization requests following standards for accuracy, timeliness, productivity, and client performance commitments.
  • Responsible for the coverage determination process, reviewing all requests which are not approvable based on specified criteria (algorithms or protocols), making all coverage denial determinations concerning drug utilization management program administration.
  • Responsible for the coordination, operation, and development of prior authorizations. 
  • Design, develop and/or deliver training to address identified needs or gaps in performance or knowledge with clinical department staff relating to prior authorization clinical content. 
  • Design and implement prior authorization, appeals, and other utilization management programs for new and existing clients, including design and development of standard and customized prior authorization and appeals notification letters.
  • Continually monitor the quality and efficiency of the coverage determination process including coverage criteria, denial language, and communication with prescribers.
  • Provide input to clinical content of new programs and for maintenance of existing programs.
  • Responsible for staying current with clinical literature and guidelines and relaying those to the program development core teams.


Professional Experience and Skills Requirements

  • B.S. in Pharmacy or PharmD. 
  • Completion of a Residency in Managed Care desired.
  • Academy of Managed Care Pharmacy (AMCP) Managed Care Certification or certification within the first six months of employment. 
  • Current, valid, and unrestricted state or local pharmacist license.
  • Active membership in a state or local pharmacy association. 
  • Two (2) to five (5) plus years related experience and/or training in coverage determinations or similarly related duties, preferred or equivalent combination of education and experience.
  • Fully bilingual: Spanish and English.
  • A thorough understanding of the managed care industries from the perspective of Pharmacy Benefit Managers and providers of care. 
  • Knowledge of financial aspects of managed care contracts, financial data, and compliance. 
  • Knowledge of Microsoft Access, Word, Excel, PowerPoint, and Outlook, as well as Internet Explorer. 
  • Ability to develop and maintain productive relationships with other internal departments, PharmPix clients, and other health care professionals. 

Additional Requirements:

The candidate must have:

  • 100% of the Covid-19 Vaccine.
  • Internet Accessibility with or more 10MB speed.
  • Must be able to work hybrid (on site and remote)

PharmPix is an Equal Employment Opportunity Employer Minorities / Females / Disable / Veterans




00968, PR
00968 USA



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