Appeals Pharmacist (Remote) at Medical Review Institute of America

Mountain View, California, United States -

Full Time

Start Date

Immediate

Expiry Date

20 Jan, 26

Salary

0.0

Posted On

22 Oct, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Pharmacy, Medication Knowledge, Customer Service, Critical Thinking, Organizational Skills, Communication Skills, Training Skills, Microsoft Office, Regulatory Guidance, Clinical Reviews, Prior Authorization, Drug Information, Compliance, Fast-Paced Environment, Team Collaboration, Operational Improvements

Industry

Hospitals and Health Care

Description

Description Who We Are - Motivated by Purpose. Powered by Clinical Expertise. Founded in 1983, we’re a clinically-driven, tech-enabled utilization management company offering expert clinical reviews, regulatory guidance, and actionable insights to healthcare organizations. Excellence starts with our people. WE OFFER A competitive compensation package. Benefits include healthcare, vision and dental insurance, a generous 401k match, paid vacation, personal time, and holidays. Growth and training opportunities. A team atmosphere with fun events and prizes scheduled throughout the year. POSITION OVERVIEW The Appeals Pharmacist is responsible for ensuring the accurate and timely review of medication prior authorization appeals. This role involves collaborating with medical professionals, ensuring compliance with clinical criteria, and serving as a source of drug information. Roles: To evaluate prior authorization appeals for drug appropriateness per policy criteria and client guidelines. To provide excellent customer service to health plan clients, practitioners, and members. To serve as an educational resource regarding drug and clinical information for all internal and external customers. Major Responsibilities or Assigned Duties: Perform case reviews for prior authorization appeals. Present cases to appeal decision committee as needed for medical director sign off. Maintain monthly and annual productivity scores per company standards. Maintain monthly and annual quality scores per company standards. Train across all queues and lines of business as requested by MRIoA leadership. Complete all client-specific training as requested by MRIoA leadership. Maintain up-to-date records of case completion. Consistently show willingness to take cases and project assignments as requested. Demonstrate respect in interactions across the company. Provide ideas for promotion and growth of the company as requested. Communicate with team and supervisor as appropriate to proactively inform of issues or concerns. Recognize and recommend operational improvements. Actively participate in the MRIoA evaluation process (both company and individual). Participate in all company meetings and committees as requested. Maintain appropriate state pharmacist license in good standing with completion of required CEs. Complete other duties as requested or approved by the Supervisor, Appeals Pharmacists, or Senior Director of Operations, ESI. Requirements Skills and Experience: Minimum of one year of experience working as a pharmacist. Experience working with commercial and Medicare Part D appeals is strongly preferred. Experience working for a health plan or pharmacy benefits manager is preferred. Ability to work in a fast-paced and high-functioning environment and meet deadlines while managing multiple high priorities. High level of medication and disease state knowledge, basic anatomy, physiology and medical terminology within the scope of pharmacy practice. Credentialed and privileged by the company's credentialing committee. Strong working knowledge of medical insurance terminology and processes. Personal computer literacy and high competency in the use of Microsoft Word, Excel, OneNote, and PowerPoint. Strong organizational skills & critical thinking capabilities with attention to detail. Strong oral and written communication skills. Well-developed customer service and training skills. Willingness to obtain additional state licensure as required for the position. Education: PharmD degree Pharmacist license in good standing Work Environment: Ability to sit at a desk, utilize a computer, telephone, and other basic office equipment is required. This role is designed to be a remote position (work-from-home). Diversity Statement: Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Drug-Free Workplace: This company is a drug-free workplace. All candidates are required to pass a Background Screen before beginning employment. All newly hired employees will take a Drug Screen, as well as agreeing to all necessary Compliance Regulations on their first day of employment. Employees are required to adhere to all applicable HIPAA regulations and company policies and procedures regarding the confidentiality, privacy, and security of sensitive health information. California Consumer Privacy Act (CCPA) Information (California Residents Only): Sensitive Personal Info: MRIoA may collect sensitive personal info such as real name, nickname or alias, postal address, telephone number, email address, Social Security number, signature, online identifier, Internet Protocol address, driver’s license number, or state identification card number, and passport number. Data Access and Correction: Applicants can access their data and request corrections. For questions and/or requests to edit, delete, or correct data, please email the Medical Review Institute at HR@mrioa.com.

Responsibilities

The Appeals Pharmacist is responsible for the accurate and timely review of medication prior authorization appeals. This role involves collaborating with medical professionals and ensuring compliance with clinical criteria.