Clinical Pharmacist – Pharmacy Appeals
| Company | CVS Health |
|---|---|
| Location | Washington, USA, Kansas, USA, Pennsylvania, USA, Oregon, USA, Delaware, USA, California, USA, Washington, DC, USA, Texas, USA, Jackson Township, NJ, USA, Florida, USA, Waterbury, CT, USA, South Carolina, USA, Georgia, USA, Arizona, USA, Concord, NH, USA, Tennessee, USA, Minnesota, USA, Rhode Island, USA, Kentucky, USA, West Virginia, USA, New York, NY, USA, Maryland, USA, Wisconsin, USA, Maine, USA, Massachusetts, USA, North Carolina, USA, Oklahoma, USA, Missouri, USA, Ohio, USA, Michigan, USA, Illinois, USA |
| Salary | $94500 – $211200 |
| Type | Full-Time |
| Degrees | |
| Experience Level | Senior |
Requirements
- 5+ years relevant work experience
- 2+ years demonstrated experience in managed care (PBM) environment
- Familiarity with wholesaler invoices
- Demonstrated ability to work under tight deadlines
- Excellent Communication, interpreting, writing and leadership skills
- Ability to prioritize, organize, and manage DOI requests
Responsibilities
- Review and resolving MAC appeals
- Leads with strategic leadership and guidance to pricing teams, ensuring effective response to pharmacy and state department of insurance (DOI) appeals are effectively reviewed and responded.
- Partner with legal to disposition pharmacy complaints and appeals that come through state agencies
- Leads and owns the process and work instruction documents that comply with state laws and meets CVS compliance
- Leads and participate in state appeals audit and exam. Provides the information to state DOI on the inquiries.
- Interprets and drafts responses to state DOI inquiries and works with CVS legal team to respond to inquiries.
- Collaborates cross-functionally with legal, compliance, network and other teams to manage the pricing appeals.
- Counsels and mentor pricing team members, providing guidance and support to enhance their pricing skills and professional development.
- Delivers pricing solutions and recommendations that drive profitability and revenue optimization and contribute to the overall financial success of the organization.
Preferred Qualifications
- 1+ years’ experience with all Pharmacy and state department of insurance appeal related processes and state regulations, and claims adjudication, including claims adjudication logic
- Proficient in Excel, MS Access, Salesforce, and Pharmacy Portal
- Adjudication system experience
- Strong mathematical problem-solving skills
- Prior PBM Knowledge