Pharmacist
Integrated Resources, Inc ( IRI ) · United States
Apply & track with Apply EdgePharmacist – Managed Care / Medicare
The Pharmacist/Clinician will conduct criteria-based and clinical reviews of medical data, perform prior authorization determinations, and apply clinical knowledge to evaluate cases according to established policies, procedures, and plan criteria.The role will also involve working with internal Prior Authorization systems and handling inbound and outbound calls with physicians, healthcare providers, patients, and internal teams regarding pending, approved, or denied prior authorizations.Key ResponsibilitiesReview and evaluate Prior Authorization (PA) requests and render coverage determinations based on clinical criteria and plan design.Verify insurance coverage and eligibility and interpret applicable clinical guideline criteria.Apply clinical knowledge and appropriate resources to perform clinical assessments and case reviews.Communicate approval and denial determinations promptly with physicians, healthcare providers, health plans, patients, and other healthcare professionals.Collaborate with technicians and Prior Authorization team members to process referrals and collect required clinical and medical information.Handle inbound and outbound calls with physicians, providers, patients, technicians, and internal PA team members.Answer clinical questions, facilitate PA requests, and resolve escalations.Maintain professional and technical knowledge of drug and disease states across Specialty and Non-Specialty Pharmacy programs.Support the Prior Authorization team and Member Services department as needed.Participate in training sessions, development meetings, related projects, and after-hours/on-call pharmacist support as required.Required QualificationsActive Pharmacist License in the applicable state of practice/residence.Bachelor's Degree in Pharmacy (BS Pharmacy) required.2+ years of Prior Authorization review experience preferred.Strong clinical review, communication, documentation, and organizational skills.Basic computer skills and ability to work effectively with pharmacy/health plan systems.Ability to manage a high-volume environment, including approximately 50 calls per day and 40 prior authorization cases per day.Proven ability to work remotely in a professional and secure environment.Availability for the complete training period and assigned schedule following training.Preferred QualificationsExperience with PBM, Managed Care, or Health Plan environments.Experience reviewing Specialty Pharmacy Prior Authorizations.Familiarity with pharmacy and healthcare platforms such as RxClaim, Facets, GuidingCare, or similar systems.Previous experience handling provider/member interactions related to Prior Authorization.PharmD preferred.Remote Work RequirementsCandidates must provide their own high-speed internet.Minimum required internet speed: 25 Mbps download / 3 Mbps upload.An Internet Speed Test screenshot must be provided.Candidates must have a smartphone to download and use the required VPN token.A dedicated and private workspace with a door is required.The workspace must be secure and inaccessible to others during working hours.Telephone conversations must not be overheard and documents/computer screens must not be visible to others.Candidates must maintain stable living accommodations suitable for remote work.Work equipment and confidential information must be protected from unauthorized access or theft.The workstation must be locked or the computer shut down when temporarily away from the workspace.Candidates must comply with applicable Teleworker Privacy Practices.The assignment may potentially be changed to an in-office assignment.