You're looking for something bigger for your career. How about inventing the future of health care? Here you'll find a professional culture where you can use your talent and our resources to make an impact on a huge scale. With better schedules than retail and more reach than any hospital, you'll open doors for yourself that simply do not exist in any other organization, anywhere. Take this opportunity to start doing your life's best work.(sm) Please note: This position requires a rotating 8 hour shift between the hours of 6 am 7 pm PST (Pacific Standard Time). This position also requires a rotating Saturday schedule as well as Sunday coverage when overtime is required. Primary Responsibilities: Evaluate prescriptions and patient histories Interpret physicians' prescriptions and clinical documentation, accesses clinical criteria and compendia support Consult with customers, patients and/or physicians regarding use of medications, potential drug interactions, and clinical status for appeals requests Conduct Quality Assurance and verify the accuracy of all prescriptions to render appeal decision Provide explanations and interpretations within area of expertise Review formulary and utilization management guidelines to determine if the drug should be a covered benefit for the beneficiary based on their medical history Research, evaluate, and make determinations on member and provider appeals of pharmacy coverage decisions Gather complex clinical information, consider approved compendia, medical literature, coverage policy, and criteria information and work within regulatory guidelines to render decisions Decision may require consulting with Plan Medical Directors and the beneficiaries treating physician Answer questions from support personnel regarding prescription drugs Position requires excellent record keeping skills, thorough documentation, clear and concise written/verbal communications skills ()
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