Clinical Pharmacist - Prior Authorization/Oncology (BCOP Required)
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Position Summary:
The Clinical Pharmacist is an operation-based role that conducts criteria based & clinical review of medical data collected to perform prior authorization as per policy and procedure. The Pharmacist/Clinician will apply clinical knowledge to plan approved criteria for reviews of cases. This role will work from CVS Caremark supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Auth team and member services department, as well as provide on-call after hours availability for urgent PA request as needed.
This position is responsible for assisting front-line colleagues (i.e. Staff Pharmacists, LPN's and Pharmacy Technicians) with oncology process/procedural support by acting as a subject matter expert (SME) and performing any other complex tasks or addressing any escalation cases assigned by leadership. This includes providing on-the-job (OJT) training, answering questions from front-line colleagues, production support, and providing recommendations/solutions to effectively streamline systems and processes. The Pharmacist will be responsible for maintaining the most current oncology therapy knowledge through self-education.
Responsibilities:
1.) Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols. One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes.
2.) Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements. Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations.
3.) Responsible for assisting front-line colleagues (i.e. Staff Pharmacists, LPN's and Pharmacy Technicians) with oncology process/procedural support by acting as a subject matter expert (SME) and performing any other complex tasks or addressing any escalation cases assigned by leadership.
4.) Assist with standard or client specific oncology review process changes as needed.
5.) Assist with writing Work Instructions when needed.
6.) Works collaboratively with internal and external business partners to provide solutions for customers, colleagues, and clients.
7.) Provide feedback of trends pertinent to oncology reviews.
8.) Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business.
9.) Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed.
This is a remote role, open to qualified candidates within the United States.
Essential Functions:
1. Regular and predictable attendance
2. Colleague may be required to work mandatory overtime/extended work week when needed
3. Colleague may be required to travel when needed
4. Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers.
5. Adhere to all policies and procedures
6. Attend on going training and development meetings
Physical Requirements:
1. Sits at desk for long periods of time (up to 100%)
2. Talking on phone for extended periods of time (up to 100%)
3. Computer use for extended periods of time (100%)
4. Reading a computer screen (up to 100%)
5. Light lifting of less than 10 lbs
Work Environment
Colleague is responsible for maintaining a HIPAA-compliant remote workspace.
Must be able to provide a quiet, uninterrupted work environment.
Must have a workstation that is not accessible to common traffic and is secure from unintentional access.
Must have stable personal high-speed internet and ability to hard-wire into company computer (cannot use wireless internet)
Education:
BS in Pharmacy or PharmD required
Board Certified Oncology Pharmacist (BCOP) required
Active, unrestricted pharmacist licensure in state of residence required
Required Skills & Other Minimum Required Qualifications:
Licensed Registered Pharmacist
Board Certified Oncology Pharmacist (BCOP) required
2+ years clinical pharmacist experience, inclusive of prior authorization experience
Knowledge of Microsoft Office Suite: Excel and Word required; Access, Outlook, PowerPoint, Visio preferable. Keyboard skills essential.
Must be able to multitask and utilize multiple system applications simultaneously.
Must be able to utilize available resources independently and provide high quality work.
Must demonstrate problem solving ability and attention to detail.
Ability to adapt and change with workflow and shifting priorities.
Ability to work effectively in a team environment and provide mentorship to non-clinical staff on the PA team.
Must possess excellent written, verbal, grammar, and listening communication skills.
Must be able to effectively communicate with a diverse customer base (internal and external) in a friendly and confident manner.
Ability to maintain confidentiality of PHI (Protected Healthcare Information).
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$45.43 - $101.54This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 05/12/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.