Coverage Review Pharmacist

Job Description :

Job Title : Coverage Review Pharmacist

Location : Remote (Tennessee License Required)

Duration : 6 months (Possible Extension)

Work Schedule : Monday Friday, 8 : 00 AM 5 : 00 PM

Position Summary

Seeking an experienced Coverage Review Pharmacist to support its Pharmacy Management team. This role focuses on performing clinical coverage determinations, prior authorizations, and appeals for prescription medications in compliance with federal and state regulations.

The ideal candidate will possess strong analytical, clinical, and regulatory knowledge, along with excellent communication skills and proficiency in compendia and Microsoft Office applications.

Key Responsibilities

• Review and process prior authorizations (PA), coverage determinations, appeals, and member grievances related to pharmacy benefits.
• Evaluate medication requests using evidence-based clinical guidelines, compendia references, and plan policies.
• Perform both prospective and retrospective reviews ensuring compliance with FDA, CMS, NCQA, and EQRO regulations.
• Develop and maintain clinical decision trees in the prior authorization system.
• Draft and review denial rationale and ensure accuracy and compliance with decision letters.
• Provide clinical input on formulary management, utilization management criteria, and pharmacy benefit design.
• Respond to inquiries from prescribers, pharmacy providers, and members within regulatory timelines.
• Collaborate with interdisciplinary teams to ensure quality, consistency, and compliance in pharmacy coverage processes.
• Maintain accurate, compliant documentation in all review systems and databases.
• Uphold confidentiality and adhere to all HIPAA and corporate compliance standards.

Required Qualifications

Preferred Qualifications

Key Competencies

Work Environment