Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria
Report to utilization review statistics to corporate compliance committees
Review data and summarize daily utilization review numbers
Responsible for tracking compliance of review cases
Provide clinical guidance and support to the assigned pharmacy technicians
Knowledge of drug coding (NDC, GCN, GPI and USC) and NCPDP claims adjudication systems
Review guideline criteria for prior authorization and non-formulary drugs in support of Pharmacy and Therapeutics Committee function and pharmacy benefit design.
Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practices
Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Requirements
Bachelor's degree or advanced degree
3+ years of experience in related field.
Current states pharmacy license.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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