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Capital Rx · 4 hours ago

Appeals Pharmacist

United States

Full-time

Remote

Entry, Mid Level

$120K/yr - $130K/yr

1+ years exp

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans. The Appeals Pharmacist is responsible for reviewing clinical coverage determinations and appeals, ensuring adherence to the appeals process, and collaborating with various stakeholders to meet client expectations.

Hospital & Health Care

H1B Sponsor Likely

Responsibilities

Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity

Performs and handles inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations

Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria

Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals

Perform peer to peer reviews with providers when requested

Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers

Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides

Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times

Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements

Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities

Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies

Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frames

Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance

Qualification

Active pharmacist licensePrior authorization experienceClinical resources proficiencyOral communication skillsWritten communication skillsMicrosoft Office SuiteMedicare appeals experienceIndependent work ability

Required

Active, unrestricted, pharmacist license required

1+ years prior authorization review or appeals experience required

Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities

Have a designated workplace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations

Strong oral and written communication skills required

Proficient in Microsoft Office Suite and experience using clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology)

Preferred

Experience working with Medicare appeals preferred

Company

Capital Rx

Capital Rx is now Judi Health! Navigate to our new page here: https://www.linkedin.com/company/judi-health

Founded in 2017

New York, NY, US

501-1000 employees

https://www.judi.health/about/careers

H1B Sponsorship

Capital Rx has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2024 (2)

2023 (1)

2022 (1)

2021 (5)