Hispanic Alliance for Career Enhancement
Clinical Pharmacist - Prior Authorization
Hispanic Alliance for Career Enhancement, Chicago, Illinois, United States
Overview
At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose‑driven colleagues — caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. This position is for a Clinical Pharmacist working in the Prior Authorization team. This is a remote role open to qualified candidates within the United States.
Responsibilities
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.
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.
Ensure that 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.
Perform inbound and outbound calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations.
Establish and maintain communication among CVS Caremark, health plan, and employer group staff.
Maintain 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.
Perform 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.
Education Bachelor's of Science - Pharmacy or Pharm.D.
Qualifications Required Qualifications
2 years' experience working as a pharmacist in a PBM setting.
Demonstrated experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology.
Prior authorization experience in a PBM setting.
Ability to prioritize, quickly assess, manage multiple tasks and adapt to constantly changing situations.
Excellent organizational skills. Strong detail orientation.
Strong Microsoft Office skills. Excellent oral and written communication skills and interpersonal skills.
Ability to work independently and make clinical decisions.
Experience using MS Office and other Windows based computer applications.
Ability to receive phone calls from prior authorization pharmacy technicians and/or providers for clinical information.
Active pharmacist license that is in good standing in the state of residence.
Preferred Qualifications
PGY1/PGY2
Prior authorization, call center and clinical experience.
Exposure to clinical and analytical problem solving.
Ability to consult with pharmacy technicians and/or physicians regarding use of medications and advise of appropriate formulary alternatives when requested.
Benefits and Details
Pay range: $45.43 - $101.54 per hour; base salary varies by experience, education, geography, and other factors. Eligible for a CVS Health bonus, commission or short‑term incentive program in addition to base pay.
Anticipated weekly hours: 40
Full‑time, remote role
Comprehensive benefits package including vacation, 10 paid holidays, health/dental/vision insurance, 401(k) plan, employee stock purchase plan, tuition reimbursement, and discount programs.
Additional Information Great benefits for great people. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Application window anticipated to close on: 10/14/2025.
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Responsibilities
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.
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.
Ensure that 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.
Perform inbound and outbound calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations.
Establish and maintain communication among CVS Caremark, health plan, and employer group staff.
Maintain 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.
Perform 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.
Education Bachelor's of Science - Pharmacy or Pharm.D.
Qualifications Required Qualifications
2 years' experience working as a pharmacist in a PBM setting.
Demonstrated experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology.
Prior authorization experience in a PBM setting.
Ability to prioritize, quickly assess, manage multiple tasks and adapt to constantly changing situations.
Excellent organizational skills. Strong detail orientation.
Strong Microsoft Office skills. Excellent oral and written communication skills and interpersonal skills.
Ability to work independently and make clinical decisions.
Experience using MS Office and other Windows based computer applications.
Ability to receive phone calls from prior authorization pharmacy technicians and/or providers for clinical information.
Active pharmacist license that is in good standing in the state of residence.
Preferred Qualifications
PGY1/PGY2
Prior authorization, call center and clinical experience.
Exposure to clinical and analytical problem solving.
Ability to consult with pharmacy technicians and/or physicians regarding use of medications and advise of appropriate formulary alternatives when requested.
Benefits and Details
Pay range: $45.43 - $101.54 per hour; base salary varies by experience, education, geography, and other factors. Eligible for a CVS Health bonus, commission or short‑term incentive program in addition to base pay.
Anticipated weekly hours: 40
Full‑time, remote role
Comprehensive benefits package including vacation, 10 paid holidays, health/dental/vision insurance, 401(k) plan, employee stock purchase plan, tuition reimbursement, and discount programs.
Additional Information Great benefits for great people. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Application window anticipated to close on: 10/14/2025.
#J-18808-Ljbffr