Appeals Pharmacist (temp-to-hire)

3 months, 2 weeks ago
Contract
Junior
Customer and Technical Support
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

Description

  • Evaluate and review appeals requests to make coverage determinations based on clinical criteria and medical necessity.
  • Handle inbound and outbound calls with physicians, healthcare providers, and patients to facilitate appeal requests, answer inquiries, and resolve escalations.
  • Collaborate with internal and external Medical Directors by providing clinical and medical information needed for reviews.
  • Interpret clinical guideline criteria and apply clinical judgment when rendering approvals and denials at all appeal levels.
  • Perform peer-to-peer reviews with providers when requested.
  • Conduct scientific literature reviews using primary, secondary, and tertiary drug resources to support recommendations.
  • Document prior authorization cases, appeals cases, and overrides thoroughly and accurately.
  • Make clinical prior authorization determinations within established turnaround times.
  • Maintain quality and productivity standards while meeting turnaround time requirements.
  • Follow internal SOPs, HIPAA guidelines, and the Capital Rx Code of Conduct, including reporting noncompliance.

Requirements

  • Active, unrestricted pharmacist license required.
  • 1+ years of prior authorization review or appeals experience required.
  • Ability to work independently with minimal supervision in a remote, high-volume, metric-driven environment with shifting priorities.
  • Designated secure workplace that is private and protected from noise during work hours.
  • Strong oral and written communication skills required.
  • 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 position.
  • Base salary range of $125,000 to $130,000 USD.
  • Opportunity to work on commercial and Medicare coverage and appeals processes in a health technology setting.

Interested in this position?

Apply directly on the company website

Apply Now

Similar Roles

Consumer Support Specialist (Weekend Shift, Sunday - Thursday)

Keeper Security 251-1K Professional Services

Keeper Security is hiring a Technical Consumer Support Specialist to support consumer customers of its cybersecurity software through phone, chat, email, and screen sharing in a remote or Chicago-area hybrid role.

Android Cybersecurity macOS
1 hour, 51 minutes ago

Customer Service Specialist - Remote, USA

Calyxo 11-50 Health Care Providers & Services

Calyxo, a Pleasanton-based medical device company focused on improving kidney stone treatment, is seeking a remote West Coast Customer Service Specialist to manage customer orders, resolve service issues, and coordinate internal fulfillment processes.

NetSuite Salesforce
2 hours, 6 minutes ago

Work From Home - Part-Time Client Services Representative

Global Elite Empire Consultants is recruiting for a part-time, fully remote financial services opportunity focused on helping clients select personalized insurance and benefits solutions while building a client-focused business.

2 hours, 21 minutes ago

Work From Home - Part-Time Client Services Representative

Global Elite Empire Consultants is recruiting part-time, fully remote representatives to provide personalized insurance and benefits solutions while building client relationships and developing financial-services expertise.

2 hours, 21 minutes ago

You're on a roll! Sign up now to keep applying.

Sign Up

Already have an account? Log in

Used by 14,729+ remote workers