Department

Job Title

Capital Rx is redefining the way prescriptions are priced and administered in the U.S. Capital Rx unlocks the pharmacy supply chain and reduces prescription costs for employer groups. By establishing a competitive marketplace for drug pricing, Capital Rx focuses its resources on deploying actionable strategies that improve plan performance and patient outcomes. The company's commitment to innovation, technology, and service is why Capital Rx is the fastest-growing pharmacy benefit manager in America.

Prior Authorization & Customer

Prior Authorization Pharmacist

Location: Remote

About Capital Rx:

Capital Rx is a next generation pharmacy benefits manager, overseeing prescription benefit plans on behalf of employers, unions, and government entities. Determined to transform an outdated model, Capital Rx’s mission is to change the way prescription benefits are priced and administered in the US, unlocking enduring social change. Through our platform approach, Capital Rx delivers data-driven insights and actionable strategies that reduce costs, while improving patient outcomes. Our commitment to innovation, technology and service is the reason why Capital Rx is among the fastest-growing PBMs in the country.

Position Responsibilities:

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• Make clinical prior authorization and appeals determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times
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• Provide detailed and thorough documentation in prior authorization cases, overrides and call center cases
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• Perform peer-to-peer reviews with providers when requested
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• Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers
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• Effectively communicate issues and resolutions to members, pharmacies, providers, and appropriate internal stakeholders
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• Provide backup support to call center team as required
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• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements
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• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities
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• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frame
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• Support staff training and development as required
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• Work collaboratively with internal business and clinical partners to support initiatives including clinical interventions, data and claims review, and on-boarding of new clients, as required
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• Provide support in clinical and claim reviews during various CMS and external audits
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• Collaborate with internal and external Medical Directors in administering appeals reviews
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Required Qualifications:

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• Active, unrestricted, pharmacist license required
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• Bachelors or Doctor of Pharmacy Degree required
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• 2+ years of pharmacy experience required
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• 1+ year of Managed care or PBM pharmacy experience required
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• Medicare Part D Appeals experience preferred
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• Proficient in Microsoft Office Suite with emphasis on Microsoft Excel
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• Have a designated workspace (an office, spare bedroom, etc.) that is visibly secure from others during work hours (closed door) and is protected from noise that could disrupt conversations
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• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities
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Base Salary: $120,000 - $125,000

This range represents the low and high end of the anticipated base salary range for the NY - based position. The actual base salary will depend on several factors such as: experience, knowledge, and skills, and if the location of the job changes.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.