Job Description
12 month Contract role with potential to go permanent
Fully remote for now possible but possibility to turn Hybrid in office 2 days a week in Durham come January 2027 MUST live within a commutable distance to Durham
- M-F 9-5 EST hours, can live in other time zones but work those EST hours
- Call Center, PBM, or Retail experience
- Must have an understanding of Medicare STARS and Metrics
- Must be comfortable on the phones interacting with members
- Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria
- Report to utilization review statistics to corporate compliance committees
- Review data and summarize daily utilization review numbers
- Responsible for tracking compliance of review cases
- Provide clinical guidance and support to the assigned pharmacy technicians
- Knowledge of drug coding (NDC, GCN, GPI and USC) and NCPDP claims adjudication systems
- Review guideline criteria for prior authorization and non-formulary drugs in support of Pharmacy and Therapeutics Committee function and pharmacy benefit design.
- Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practices
- Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Hiring Requirements
- Bachelor's degree or advanced degree
- 3+ years of experience in related field.
- Current states pharmacy license.
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