You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
 

Clinical Pharmacist (Appeals)

Position Purpose: The Clinical Pharmacist processes review prior authorization requests for non-formulary medications for clinical appropriateness. This assures members receive the most effective and cost effective pharmacological therapies.

• Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician’s recommended denial, suggested formulary alternatives, comments and attachments for appropriateness.

• Verifies member’s ID number and date of birth.

• Verifies member’s eligibility in the appropriate health plan eligibility system.

• Records carrier and group number if applicable.

• Checks for previous prior authorization decisions.

• Verifies coverage in member’s prescription benefit when necessary.

• Verifies coverage in member’s health plan benefit when necessary.

• Evaluates prescription claim history.

• Reviews chart notes and/or lab values.

• Identifies provider specialty when appropriate.

• Applies Medical Policy Criteria to prior authorization requests.

• Evaluates whether request meets criteria for approval.

• Reviews the request using professional clinical judgment on a case by case basis. A pharmacist will review medication requests not addressed by P&T Committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.

• Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool

• Communicates with physicians regarding prior authorization:

  • For a non-formulary drug

  • Plan benefits, exclusions

  • Quantity limits

  • Age restrictions

  • Formulary alternatives

• Retrieves and collects data through available reporting resources (i.e. Discoverer, IT Department)

• Compiles data for reporting purposes:

  • Drug utilization of non-formulary drugs

  • Overturned IPS recommended denials

  • Audit pharmacy claims greater than $200.00

  • Suggest addition or deletion of drugs to/from the formulary

  • Updating qty/days or age limit ends

  • Support National P&T Committee

  • Other tasks which may arise during the performance of any of the above mentioned duties

Education/Experience: Bachelor’s or Doctor of Pharmacy degree. One-year prior experience.

License/Certification: Must have and maintain current, valid and unrestricted Pharmacist license in the state of employment and credentialed by the health plan of employment. May be required to obtain additional state licensure based on business needs.

Previous Pharmacy Appeals with Medical Pharmacy or Prior Authorization experience, highly preferred.

Working Shift: 9am - 5:30pm (EST) with weekend rotation every 12-14 weeks. Will be added to the rotation once fully trained in all lines of business.

Job Specific Details:  Review coverage requests for Pharmacy Appeals, Medical Pharmacy Appeals, and Direct Member Reimbursement requests.

Pay Range: $103,500.00 - $191,600.00 per year

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.  Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.  Total compensation may also include additional forms of incentives.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act