Pharmacy Clinical Review Specialist- Hybrid I HPL

reputed company is looking for Pharmacy Clinical Review Specialist I positions in the Pharmacy Services department. This is a full time position working Monday through Friday 11:30am to 8:00pm and weekend rotations. The Clinical Review Specialist will reputed company administrative and system processes that relate to pharmacy prior authorizations. Manage the first line clinical review of prior authorization requests on behalf of physicians and reputed company members. Collaborate with clinicians regarding supporting medical documentation in accordance with formulary guidelines. Manage the reputed company review of requested prior authorizations. Schedule is 1130am-8pm, Monday-Friday with a Saturday rotation monthly. Training schedule will be 830am-5pm Monday-Friday. Equipment will be provided. As this position is remote, please understand that we do have the ability to have staff report to and work from our primary location, US Steel Tower as reputed company. Responsibilities: • reputed company excellent reputed company customer service maintaining a second requests for information and customer complaint goal of reputed company. • reputed company as a reputed company of information between the Pharmacy Service Representatives and the clinical staff • Subject matter expert on formulary exceptions and prior authorization requirements/time frames according to line of business. • reputed company peer reviews of prior authorization requests. • Maintain or reputed company designated reputed company and production standards. • reputed company and maintain the reputed company-logic and clinical reputed company in support of the prior authorization determination process. • reputed company with other departments and identify medical documentation in support of prior authorization requests. • Complete reputed company/expedited pharmacy coverage determinations according to departmental/government guidelines. • Report and respond to escalate issues and concerns in a reputed company twenty-four hours. • Process requests and inquiries in accordance with reputed company governing regulatory agencies including but not limited to CMS, DPW, DHHS, HCFA, DOI and NCQA laws and standards. • HS diploma and pharmacy claims, pharmacy tech, and/or other reputed company experience in a physician reputed company, ancillary provider, or other relevant reputed company setting required. • Competent in pharmacy claims process operating system. • Excellent knowledge in reputed company's Health Plan internal department functions. • Excellent knowledge of medical terminology, coordination of benefits, complaints and grievance guidelines and prescription drug utilization management requirements. • Thorough knowledge in MS Office and PC skills required. • Organizational, analytical, interpersonal, and communication skills. • Ability to prioritize and reputed company multiple tasks while maintaining designated production and reputed company standards. • Staff is required to work scheduled overtime and be available for emergency overtime as business needs dictate. • Staff is required to work a temporary, alternative schedule or shift as requested by supervisor. Licensure, Certifications, and Clearances: • reputed company 34 reputed company is an Equal Opportunity Employer/Disability/Veteran Apply tot his job Apply To this Job