Clinical Pharmacist Advisor

Job Description

Job Summary:

• As a Clinical Pharmacist Advisor Medicare you will be directly supporting Medicare Part D members and providers with requests related to their pharmacy benefits.
• You will be responsible for ensuring cases are accurately set up for our members, review clinical information for decisioning the request, performing outreach to providers for more information when needed, and ensuring accurate decisions that comply with compendia and Medicare guidance and timelines.
• This is a great opportunity to initiate a career with a leading healthcare company by reviewing information and completing timely and accurate documentation of all Medicare Part D requests, in compliance with Medicare guidelines, while promoting a best-in-class service experience.

Duties and Responsibilities:

• The role involves ensuring the accuracy of case setup and clinical review of Medicare appeals cases by thoroughly reviewing internal notes or fax requests for pertinent information, providing clear and concise documentation, and contacting providers when necessary to obtain clinical details for case decisions.
• It requires adherence to work instructions and Medicare guidelines to ensure proper case processing.
• The position also demands compliance with CMS-mandated timelines, as well as departmental productivity and quality standards.
• Clinical judgment and knowledge must be applied effectively, utilizing drug compendia resources, evolving work instructions, and CMS Medicare guidance.
• Additionally, the role includes participating in development discussions and receiving feedback from the direct supervisor to support continuous improvement.

Education and License:

• Bachelor’s degree in pharmacy or Pharm D. required.
• Must have an active license in good standing in state of residence.
• Licensed Registered Pharmacist in state of residence.

Experience:

• Previous experience in Managed Care/PBM environment (preferred).

Knowledge:

• Knowledge of Access, Power Point, and Visio is preferable.
• Must be computer literate – knowledge of Excel and Word.