12 month Contract role with potential to go permanent
Fully remote for now possible but possibility to turn Hybrid in office 2 days a week in Durham come January 2027 MUST live within a commutable distance to Durham
M-F 9-5 EST hours, can live in other time zones but work those EST hours
• Call Center, PBM, or Retail experience
• Must have an understanding of Medicare STARS and Metrics
• Must be comfortable on the phones interacting with members
• Review prior authorization requests and make determinations for drug products according to member benefits and coverage criteria
• Report to utilization review statistics to corporate compliance committees
• Review data and summarize daily utilization review numbers
• Responsible for tracking compliance of review cases
• Provide clinical guidance and support to the assigned pharmacy technicians
• Knowledge of drug coding (NDC, GCN, GPI and USC) and NCPDP claims adjudication systems
• Review guideline criteria for prior authorization and non-formulary drugs in support of Pharmacy and Therapeutics Committee function and pharmacy benefit design.
• Ensure and evaluate quality controls and implement opportunities for performance improvement in pharmacy practices
• Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews
Hiring Requirements
• Bachelor's degree or advanced degree
• 3+ years of experience in related field.
• Current states pharmacy license.