You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking a Prior Authorization Pharmacist to review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria. The role involves maintaining thorough records, responding to clinical inquiries, supporting pharmacy staff, and identifying potential improvements and fraud, waste, or abuse.
Key Responsibilities
- Review and make timely, evidence-based decisions on prior authorizations, appeals, and override requests using clinical guidelines and benefit criteria.
- Accurately document clinical decisions and maintain thorough records in accordance with regulatory and accreditation standards (URAC/NCQA).
- Respond to clinical inquiries from members, prescribers, and pharmacies with professionalism, active listening, and a patient-centered approach.
- Act as support to pharmacy technician and provide training and education where needed.
- Work in partnership with pharmacy staff to assist in the implementation of utilization management programs.
- Collaborate with Program Manager to help with workflows and operational efficiencies.
- Identify and report potential fraud, waste, and abuse.
- Evaluate opportunities for operational or process improvements.
- Perform other duties as assigned.
Qualifications
- PharmD degree or Bachelor’s degree in Pharmacy.
- Active and unrestricted Pharmacist license in good standing in the state of Residence.
- Proven solid drug product and clinical pharmacy knowledge.
- Ability to work independently and as part of a team in a fast-paced environment.
- Strong communication and software skills.
Experience
- Prior authorization experience in PBM or managed care environment preferred.
- Experience working in Prior Authorization.
- Experience making coverage determinations.
Additional Requirements
Work hours are 8:30 AM to 5:00 PM, Monday to Friday PST, with some flexibility including an occasional Saturday if required.
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
*As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients
