Appeals Pharmacist (temp-to-hire)
$101,600–$133,000 year
Remote · United States
Job Summary
Evaluate and review clinical appeals and coverage determinations for Commercial and Medicare lines; perform and coordinate inbound/outbound calls with physicians, providers, and patients to facilitate appeals, answer inquiries, and resolve escalations. Collaborate with Medical Directors and provide clinical data for reviews, interpret guideline criteria, and render approvals/denials across levels of appeals. Conduct peer-to-peer reviews, perform literature evaluation to support recommendations, document thoroughly in prior authorization and appeals cases, and ensure decisions align with medical necessity and benefit guidelines within established turnaround times. Maintain HIPAA-compliant practices and adhere to SOPs; deliver high-quality customer care in a fast-paced, remote environment while supporting Capital Rx Code of Conduct.
Required Qualifications
- Active, unrestricted pharmacist license required
- 1+ years prior authorization review or appeals experience required
- Ability to work independently with minimal supervision, remote high-volume, metric-driven environment
- Designated workplace secure from others during work hours
- Strong oral and written communication skills
- Proficient in Microsoft Office Suite and clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology)
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