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Appeals Pharmacist (temp-to-hire)

1 month, 2 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 3

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

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