Clinical Pharmacist - Prior Authorization

- Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements.

- Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols.

- One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes.

- Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations.

- Establishes and maintains communication among CVS Caremark, health plan, and employer group staff.

- Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business.

- Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed.We offer a competitive benefit package including vacation, 10 paid holidays per year, health/dental/vision insurance, employee discounted stock purchase program, 401K, tuition reimbursement, and 20-30% employee discount at all CVS stores.This is a remote role open to candidates within the United States.Required Qualifications

• 2 years' experience working as a pharmacist in a PBM setting.

• Current experience working with commercial Prior Authorizations in PBM

• Experience using clinical resources, e.g., Micromedex, Lexicomp, Clinical Pharmacology

• Ability to prioritize, quickly assess, manage multiple tasks and adapt to constantly changing situations.

• Excellent organizational skills. Strong detail orientation.

• Strong Microsoft Office skills. Excellent oral and written communication skills and interpersonal skills.

• Ability to work independently and make clinical decisions.

• Experience using MS Office and other Windows based computer applications.

• Ability to receive phone calls from prior authorization pharmacy technicians and/or providers for clinical information.

• Active pharmacist license that is in good standing in the state of residence.Preferred Qualifications

• PGY1/PGY2

• Prior authorization, call center and clinical experience.

• Exposure to clinical and analytical problem solving.

• Ability to consult with pharmacy technicians and/or physicians regarding use of medications and advise of appropriate formulary alternatives when requested.Education

Bachelor's of Science - Pharmacy or Pharm.D. Anticipated Weekly Hours
40Time Type
Full timePay Range

The typical pay range for this role is:$50.48 - $84.62This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefitsWe anticipate the application window for this opening will close on: 06/30/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.