Coverage Review Pharmacist

TL;DR

Coverage Review Pharmacist (Medical): Performing prospective and retrospective coverage reviews and appeals for medications with an accent on clinical criteria application and regulatory compliance. Focus on ensuring accurate, evidence-based coverage determinations while leveraging AI-enabled tools to support clinical decision-making.

Location: Must be based in the USA (Remote)

Company

hirify.global is a health insurance provider dedicated to ensuring quality care and regulatory compliance for its members.

What you will do

• Perform prospective and retrospective coverage reviews and appeals for self-administered and provider-administered medications.
• Apply evidence-based clinical criteria and state/federal regulatory requirements to coverage determinations.
• Maintain denial rationales and ensure decision letters meet compliance standards.
• Serve as a clinical resource for basic to mid-level reviews.
• Participate in an alternating team on-call rotation, including weekends.
• Utilize AI-enabled tools to improve efficiency and serve members effectively.

Requirements

• Doctor of Pharmacy (PharmD) degree required.
• Licensed in Tennessee or eligible for licensure within 120 days of employment.
• 3 years of clinical experience or 1 year of residency/board certification.
• Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS).
• Must be available for weekend on-call shifts every few weeks.
• Sponsorship is not available for this position.

Nice to have

• Prior experience using NovoLogix or MHK systems.

Culture & Benefits

• Encourages innovation and the responsible use of AI-enabled tools.
• Collaborative and highly organized team environment.
• Focus on autonomous work and clinical rigor.
• Full-time employment with a major health insurance provider.