Company Overview
Capital Rx is a healthcare technology company advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp™, the company is executing its mission through the deployment of JUDI®, Capital Rx’s cloud-native enterprise health platform, and an efficient Single-Ledger Model™, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one platform, servicing over 2.4 million members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.
About the job
Location: Remote (For Non-Local) or Hybrid (Local to NYC area)
Position Summary
A Prior Authorization (PA) Pharmacist at Capital Rx performs day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests and inbound and outbound member and provider education calls while following medical necessity and contract criteria.
Position Responsibilities
- Perform day to day clinical pharmacy functions including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
- Make clinical decisions in accordance with medical necessity and contract criteria
- Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers
- Communicate effectively with providers and members to promote positive health outcomes
- Provide backup support to call center team as required
- Review pharmacy claims data for proactive outreach and intervention
- Support staff training and development as required
- Identify and monitor inappropriate trends in care to improve quality and cost effectiveness
- Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements
- Supports quality improvement programs/projects as required (~5% of time)
- Provide support for clinical programs including creation and maintenance of prior authorization criteria guidelines and decision trees
- Work with business and clinical partners as needed
- Ability to work in a fast-paced environment with shifting priorities
- Work on scheduled shift – please see schedule details under minimum qualifications section for required working hours
- Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance
Minimum Qualifications
- Active, unrestricted, pharmacist license required
- Bachelors or Doctorate of Pharmacy Degree required
- 2+ years of pharmacy practice experience required
- Managed care or PBM pharmacy experience required
- Medicare Part D experience preferred
- Proficient in Microsoft office Suite with emphasis on Microsoft Excel
- Available to work during peak season from January-March (no planned extended vacations will be approved)
- Available to work a shift from 2pm-11pm EST that will be assigned to you, along with rotating weekends
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