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Appeals Pharmacist (temp-to-hire)

1 month, 4 weeks ago
United States
Contract
Junior
Customer Support
Customer and Technical Support
HIPAA
Apply Now
Capital Rx

Capital Rx

Capital Rx provides comprehensive health benefit management and transparent pharmacy benefit management solutions, integrating various healthcare services to support millions of plan members across diverse sectors.

Health Care Providers & Services
251-1K
Founded 2017
View All Jobs 9

Description

  • Evaluate appeals requests and render coverage determinations based on clinical criteria and medical necessity.
  • Handle inbound and outbound calls with physicians, healthcare providers, and patients to support appeals and resolve escalations.
  • Collaborate with internal and external Medical Directors by providing clinical and medical data for reviews.
  • Interpret clinical guideline criteria and make approval or denial decisions on appeals.
  • Perform peer-to-peer reviews with providers when requested.
  • Evaluate scientific literature and drug resources to support recommendations and decision-making.
  • Document prior authorization cases, appeals cases, and overrides thoroughly and accurately.
  • Make prior authorization determinations in accordance with medical necessity and covered benefit guidelines.
  • Maintain quality, productivity, and turnaround-time standards for reviewed cases.
  • Follow internal SOPs and HIPAA guidelines while delivering customer service in a fast-paced environment.

Requirements

  • Active, unrestricted pharmacist license.
  • 1+ years of prior authorization review or appeals experience.
  • Ability to work independently with minimal supervision in a remote, high-volume, metric-driven environment with shifting priorities.
  • Designated secure workspace with privacy and limited noise during work hours.
  • Strong oral and written communication skills.
  • Proficiency in Microsoft Office Suite.
  • Experience using clinical resources such as Micromedex, Lexicomp, or Clinical Pharmacology.
  • Experience working with Medicare appeals preferred.

Benefits

  • Remote, US-based role.
  • Base salary range of $101,600 to $133,000 USD.
  • Opportunity to work on a healthcare technology platform serving employers, unions, health plans, government entities, and millions of Americans.

Interested in this position?

Apply directly on the company website

Apply Now

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