Appeals Pharmacist (temp-to-hire)

About the company

The company is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. The company replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, the company helps clients achieve unprecedented operational efficiency and service levels.

At the company, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit [link for members] .

Position Summary

Responsible for reviewing clinical coverage determination and appeals for different lines of business such as Commercial and Medicare. Knowledgeable in all aspects of coverage determination and appeals process and assist in meeting client expectations regarding efficiency and quality decision making.

Position Responsibilities

• Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity. Performs and handles inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations.

• Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria.

• Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals.

• Perform peer to peer reviews with providers when requested.

• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers.

• Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides.

• Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times.

• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.

• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.

• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.

• Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frames.

Minimum Qualifications

• Active, unrestricted, pharmacist license required

• 1+ years prior authorization review or appeals experience required

• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities

• Have a designated workplace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations

• Strong oral and written communication skills required

• Proficient in Microsoft Office Suite and experience using clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology)

Preferred Qualifications

• Experience working with Medicare appeals preferred

This range represents the low and high end of the anticipated base salary range. The actual base salary will depend on several factors such as: experience, knowledge, skills, and location of the job.

Remote, US Salary Range

$120,000 — $135,000 USD

All employees are responsible for adherence to the company Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at the company. More details about the company's privacy practices can be found at   [link for members] .