Clinical Pharmacist - Prior Authorization

About the position

The Clinical Pharmacist - Prior Authorization role at CVS Health involves evaluating and reviewing prior authorization requests, making coverage determinations based on clinical criteria, and ensuring effective communication with healthcare providers and patients. This position requires collaboration with team members to process referrals and maintain up-to-date knowledge of drug and disease states relevant to the pharmacy programs. The role is essential in delivering high-quality healthcare services while adhering to departmental protocols and service level agreements.

Responsibilities

• Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design.
• Verify insurance coverage and eligibility, interpret clinical guideline criteria, and consult with healthcare providers.
• Communicate decisions regarding cases promptly to healthcare providers, health plans, and patients.
• Collaborate with technicians and team members to process referrals and collect necessary clinical data.
• Handle inbound and outbound phone calls to facilitate prior authorization requests and resolve inquiries.
• Maintain professional knowledge of drug and disease states for Specialty and Non-Specialty Pharmacy programs.
• Attend training sessions and development meetings, and provide on-call and after-hours pharmacist availability as needed.

Requirements

• 2 years' experience working as a pharmacist in a PBM setting, including prior authorization experience.
• Demonstrated experience using clinical resources such as Micromedex and Lexicomp.
• Ability to prioritize and manage multiple tasks in a fast-paced environment.
• Excellent organizational skills and strong attention to detail.
• Strong Microsoft Office skills and excellent communication skills.
• Ability to work independently and make clinical decisions.
• Active pharmacist license in good standing in the state of residence.

Nice-to-haves

• PGY1/PGY2 residency training.
• Prior authorization, call center, and clinical experience.
• Exposure to clinical and analytical problem solving.
• Ability to consult with pharmacy technicians and physicians regarding medication use.

Benefits

• Vacation and paid time off (PTO)
• 10 paid holidays per year
• Health, dental, and vision insurance
• Employee discounted stock purchase program
• 401K retirement savings plan
• Tuition reimbursement
• 20-30% employee discount at CVS stores