Appeals Pharmacist (Healthcare)

TL;DR

Appeals Pharmacist (Healthcare): Reviewing clinical coverage determinations and appeals for Commercial and Medicare lines of business with an accent on clinical criteria and medical necessity. Focus on evaluating appeals requests, conducting peer-to-peer reviews, and ensuring adherence to HIPAA and health plan guidelines.

Location: Remote (Must be based in the US)

Salary: $125,000 - $130,000 USD

Company

Enterprise health technology company providing pharmacy benefit management (PBM) and health benefit management solutions via its proprietary platform.

What you will do

• Evaluate appeals requests to render coverage determinations based on clinical criteria and medical necessity.
• Collaborate with Medical Directors by providing necessary clinical and medical data for reviews.
• Perform peer-to-peer reviews with providers and evaluate scientific literature using drug resources.
• Provide thorough documentation for prior authorization, appeals cases, and overrides.
• Maintain quality and productivity standards while meeting established turnaround times.
• Ensure strict adherence to HIPAA guidelines and the company Code of Conduct.

Requirements

• Active, unrestricted pharmacist license required.
• 1+ years of experience in prior authorization review or appeals.
• Must be based in the US with a designated, secure, and quiet home office workspace.
• Proficient in Microsoft Office Suite and clinical resources like Micromedex, Lexicomp, or Clinical Pharmacology.
• Strong oral and written communication skills for interacting with physicians and patients.

Nice to have

• Experience working specifically with Medicare appeals.

Culture & Benefits

• Full remote work arrangement.
• Opportunity to work with a company rebuilding trust in the US healthcare infrastructure.
• Inclusive workplace celebrating diversity and equal employment opportunities.