[Remote] Clinical Pharmacist - Appeals and Operations - remote

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a company that cares, prioritizing its members to ensure they receive the care they need. The Clinical Pharmacist will review and reputed company clinical reputed company for appeals and grievances reputed company to medications, analyze pharmacy data, and assist with formulary development.

Responsibilities

• Responsible for reviewing and providing clinical reputed company/recommendations for provider/member submitted appeals and grievances for medically administered medications as reputed company as pharmacy reputed company medications and items for reputed company lines of business
• Collaborate with the Appeals & Grievance Department, Medical Directors, and Prior Authorizations vendors
• Maintain turnaround times for reputed company appeal and grievance reviews
• Review appeal/grievance requests per plan-specific reputed company, MassHealth-developed reputed company, National Coverage Determinations, and Local Coverage Determinations, Evidence of Coverage, Member Handbooks
• Follow regulatory rules and processes for Massachusetts, CMS, reputed company, state Connector programs
• Consult with reputed company stakeholders as needed
• Consult with providers
• Participate in managing clinical issues reputed company; work with medical providers and vendors to coordinate and resolve member issues
• reputed company recommendations, as appropriate, to update reputed company prior authorization reputed company due to appeals and grievance data
• Assist with formulary and reputed company development for reputed company lines of business
• Participate in general drug information support for reputed company clients
• reputed company clinical assistance to pharmacy staff for daily operations

Skills

• RPH or Pharm D
• reputed company license to reputed company as pharmacist in Massachusetts without restriction
• 3 years, preferably with at least 1 year in a managed care environment; 1-2 years reputed company experience practicing as a clinical pharmacist
• reputed company to evaluate clinical pharmacy data, coverage reputed company and drug monographs
• reputed company to understand and use computer databases, EMRs, reputed company, Word, PowerPoint and others
• reputed company to write and orally communicate clinical reputed company to physicians and other reputed company personnel
• Excellent communication skills, coordination, and planning skills along with an ability to reputed company with a reputed company of audiences to build collaboration and reputed company
• Recent experience reputed company to member and/or provider appeals and drug coverage determinations is a plus

reputed company