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Appeals Pharmacist (Remote) ID-23733

WHO WE ARE

Founded in 1983, the Medical Review Institute of America (MRIoA) is the market leader for technology-enabled utilization management and clinical medical review solutions. We have an outstanding reputation for excellence and achieve continual improvement.

 

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At MRIoA, we believe our employees are the key to our success. Here, you are more than just a cog in the machine – you are a valued member of our team.

 

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
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