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Pharmacist, Clinical Grievance and Appeals ID-11077

Navitus
Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.
USD $98,384.00 - USD $122,980.00 /Yr.
Remote Moderator, $42/hr, College Student, Weekend Job Phone Support, $45/hr, Remote, No Experience, Evening Job Entry Level Phone Job, $40/hr, Remote, No Degree Required Data Entry, Remote, $40/hr, Night Shift, No Degree Remote Phone Job, $42/hr, Part-Time, No Experience Required Remote Customer Support, $40/hr, Part-Time, College Student Virtual Assistant, $40/hr, Remote, Weekend, Entry Level Virtual Assistant, No Degree, $40/hr, Remote, Part-Time Evening Virtual Assistant, Remote, $45/hr, No Experience Data Entry, $50/hr, Night Shift, No Degree, Remote Job Virtual Assistant, $42/hr, Remote, No Experience, Evening Remote Data Entry, $40/hr, No Degree, Night Shift Weekend Data Entry, $40/hr, Remote, No Experience Customer Support, $40/hr, Weekend Job, Remote, No Degree Data Entry, Remote, $40/hr, Night Shift, No Degree Phone Job, $40/hr, Remote, Night Shift, No Degree Customer Support, $40/hr, Remote, Part-Time, No Degree Part-Time Data Entry, $40/hr, Remote, College Student Friendly Phone Job, $35/hr, Remote, Part-Time, College Student Remote Customer Support, $45/hr, No Experience, Part-Time Remote Phone Support, $40/hr, Night Job, College Student Remote Customer Support, $50/hr, Night Shift, No Degree Virtual Assistant, $42/hr, Remote, Weekend, Entry Level Remote Live Chat, $50/hr, Part-Time, Evening/Night Job Remote Data Entry, $40/hr, College Student Friendly, Part-Time Data Entry, $35/hr, Night Shift, No Degree,?Remote?Job Phone Support, Remote, $42/hr, Evening/Night Shift Data Entry, $45/hr, Remote, Evening, No Experience Required Customer Support, $42/hr, Remote, Part-Time, No Degree Remote Live Chat, $40/hr, College Student, No Experience Data Entry, $40/hr, Part-Time, Remote, Weekend Job Remote Data Entry, $40/hr, Evening/Night Job, No Experience Customer Support, $35/hr, Remote, Evening/Night Job, No Degree Weekend Data Entry, $45/hr, Remote, No Experience Remote Customer Support, $45/hr, No Experience, Part-Time Virtual Assistant, $50/hr, Evening, Remote, College Student Phone Job, $45/hr, Remote, Night Shift, No Degree Remote Data Entry, $40/hr, Evening/Night Job, No Experience Live Chat Support, $45/hr, Weekend, Remote, College Student Remote Phone Support, $40/hr, Night Job, College Student Data Entry, $40/hr, Part-Time, Remote, Weekend Job Remote Customer Support, $40/hr, Night Job, No Experience Remote Customer Support, $50/hr, Night Shift, No Degree Remote Moderator, $35/hr, No Degree, Weekend, Part-Time Data Entry, $40/hr, Remote, Evening, No Experience Required Virtual Assistant, No Experience, $42/hr, Remote, Weekend Customer Support, $50/hr, Remote, Evening/Night Job, No Degree Live Chat Support, $50/hr, Remote, Night Shift, No Degree Entry-Level Remote Data Entry, $35/hr, Evening Job Remote Data Entry, $45/hr, Weekend Job, College Student Remote Moderator, $40/hr, Weekend, No Experience Required Remote Virtual Assistant, $40/hr, Evening, Part-Time Job Virtual Assistant, No Experience, $40/hr, Remote, Part-Time Remote Phone Job, $42/hr, Part-Time, College Student Friendly Remote Customer Support, $35/hr, Night Shift, No Degree Virtual Assistant, Remote, $40/hr, Evening, No Experience Virtual Assistant, $42/hr, Remote, No Experience, Evening Entry-Level Remote Data Entry, $35/hr, Evening Job Data Entry, Remote, $40/hr, Evening Job, No Degree Virtual Assistant, No Experience, $42/hr, Remote, Part-Time Remote Moderator, $35/hr, No Degree, Weekend, Part-Time Remote Moderator, $35/hr, No Degree, Weekend, Part-Time Phone Job, $45/hr, Remote, Night Shift, No Degree Virtual Assistant, No Experience, $42/hr, Remote, Part-Time Remote Moderator, $42/hr, Part-Time, Weekend, No Degree Remote Phone Job, $45/hr, No Degree, College Student Friendly Live Chat Support, $45/hr, Weekend, Remote, College Student Data Entry, $40/hr, Remote, Evening, No Experience Required Remote Live Chat, $40/hr, College Student, No Experience Virtual Assistant, $40/hr, Weekend, Remote, No Experience Phone Job, $50/hr, Remote, No Degree, Part-Time, Weekend Remote Phone Job, $35/hr, College Student, Night Shift Remote Phone Job, $42/hr, Part-Time, College Student Friendly Remote Customer Support, $45/hr, No Experience, Part-Time Remote Data Entry, $40/hr, College Student Friendly, Part-Time Customer Support, $35/hr, Remote, Evening/Night Job, No Degree Data Entry, $50/hr, Night Job, No Degree, Remote Live Chat Support, $35/hr, Remote, Night Shift, No Degree Remote Moderator, $40/hr, Part-Time, Weekend, No Degree Data Entry, $40/hr, Part-Time, Remote, Weekend Job M-F 8am-5pm, CST; rotating weekends
ATTENTION: Navitus is unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

Due to growth, we are adding a Grievance and Appeals Pharmacist to our Grievance and Appeals department!

 

The Clinical Grievance and Appeals Pharmacist will be responsible for performing Appeals and Redeterminations, Grievance Quality of Care reviews, perform duties related to Drug Utilization Review including concurrent, retrospective, and prospective components, and serve as a liaison and clinical support the Grievance and Appeals staff for clinical calls requiring pharmacist intervention. The Clinical Grievance and Appeals Pharmacist is also responsible for interfacing with physicians, pharmacists, and specialty pharmacy providers with respect to beneficiaries’ benefits and therapeutic interventions. Additional responsibilities include reviewing/evaluating the health surveys and utilizing data for program management and development. The Clinical Grievance and Appeals Pharmacist will coordinate with Clinical Account Executives and Program Managers to enhance their support and understanding of related Pharmacy Benefit Management (PBM) programs. Additionally, the Clinical Grievance and Appeals Pharmacist will develop and maintain appropriate clinical, evidence-based documentation that supports PBM programs. The primary functions involve ensuring that Navitus can provide clinically sound programs and medications in the most cost-effective manner and utilize technology to implement on-line PBM programs.

 

Is this you? Find out more below!


How do I make an impact on my team?

  • Responsible for support and input to clinical programs such as Health Management, Drug Utilization Review, Formulary development, and clinical programs to encourage appropriate, high-quality, cost-effective drug therapy; and to identify opportunities for improvement in efficiency, accuracy, and appropriateness of the programs in place
  • Perform quality reviews of: Prior Authorization forms, denial Language, PA Accel
  • Continually monitor the quality and efficiency of the Appeals, Redetermination and Grievance process including coverage criteria, denial language, and communication with prescribers
  • Review Grievances, Appeals, Complaints, and Redeterminations following all CMS, state, client, and Navitus standards
  • Provide input to clinical content of new programs and for maintenance of existing programs
  • Participate in audits, on-site or remote audits, as a clinical subject matter expert
  • Responsible for supporting/providing clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee
  • Learn and understand the up and downstream processes related to grievances and appeals
  • Contribute to the management of grievance and appeal resources/materials
  • Other duties as assigned


What our team expects from you?

  • A minimum of a bachelor’s degree in Pharmacy or Pharm D
  • Current unrestricted licensure as an RPh in the State of the home office of the pharmacist, or the ability to gain reciprocity within 4 months of employment is required
  • Preferred experience is a minimum two years of clinical experience, or clinical or managed care pharmacy practice residency
  • Knowledge of PBM industry, formulary management, utilization review, pharmacy claims and managed care principles and practices desired
  • Proficiency in drug literature and clinical trial evaluation, including proficiency with electronic databases (e.g., Micromedex, Medline) preferred
  • Ability to reason and translate clinical information into a manner appropriate for clinical systems and clinical/non-clinical audiences
  • Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
  • Strong attention to detail to assure projects are clinically, editorially, and systems accurate and can be operationalized
  • Proficiency in MS Word, Excel, and Power Point including tables, charts and figures preferred
  • Participate in, adhere to, and support compliance program objectives
  • The ability to consistently interact cooperatively and respectfully with other employees
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