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Responsibilities
Position Summary:
- As a Clinical Pharmacist Advisor, Medicare B Operations, you will support Medicare Part B members, prescribers, and providers by processing coverage-related requests for injectable and infused medications covered under their medical benefits.
- You will be responsible for accurate case set up, review of clinical information for decisioning the request, performing outreach to providers for more information when needed, and ensuring accurate decisions that comply with compendia and Medicare guidelines, CMS-mandated timelines, and internal quality standards.
- You will demonstrate strong attention to detail, professional verbal and written communication skills, and the ability to problem-solve in a highly regulated, fast-paced environment.
- This is a great opportunity to initiate a career with a leading healthcare company by reviewing information and completing timely and accurate documentation of Medicare Part B requests, in compliance with Medicare guidelines, while promoting a best-in-class service experience.
- This position is full-time, remote, non-exempt, and requires schedule flexibility based on business needs.
Schedule:
- Business Hours are 7am - 8pm EST Monday - Friday and 7am - 4:30pm EST Saturday and Sunday.
- Set rotation.
Interview Process:
- Virtual interviews with supervisors via Teams.
Requirements:
- Licensed Registered Pharmacist in state of residence.
- Bachelor's degree in pharmacy or Pharm D. required.
- Must have an active license in good standing in state of residence.
- Knowledge of Access, Power Point, and Visio is preferable.
- Must be computer literate, including knowledge of Excel and Word.
Case Review and Processing:
- Process incoming coverage-related requests from members and prescribers.
- Accurately set up cases, review documentation, and apply work instructions to ensure correct and timely processing.
- Read, analyze, and interpret business and medical correspondence, technical procedures, and Medicare regulations to support decision-making.
Outreach and Information Gathering:
- Conduct outbound calls to members and providers to obtain missing or additional information required to complete requests.
- Communicate clearly, professionally, and empathetically while projecting a positive business image.
Documentation, Accuracy, and Compliance Standards:
- Provide clear, concise, and accurate documentation of all case activity across systems.
- Ensure all cases are properly closed and meet CMS-mandated timelines, department productivity expectations, and quality standards.
- Apply clinical judgment and knowledge effectively, utilizing drug compendia resources, evolving work instructions, and CMS Medicare guidance.
Continuous Learning and Development:
- Acquire and maintain working knowledge of evolving work instructions, systems, and Medicare guidance.
- Participate in coaching, feedback, and development discussions with direct leadership.
Experience:
- Previous experience in managed care, PBM environment, institutional healthcare, pharmacy, or related experience is preferred.
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