You could be the one who changes everything for our 25 million membersCentene is transforming the health of our communities, one person at a timeAs a diversified, multi-national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
Position purpose:
The clinical pharmacist processes review prior authorization requests for non-formulary medications for clinical appropriatenessThis assures members receive the most effective and cost effective pharmacological therapies.
Reviews a completed prior authorization request received from the provider and/or reviews the pharmacy technician’s recommended denial, suggested formulary alternatives, comments and attachments for appropriateness.
Verifies member’s id number and date of birth.
Verifies member’s eligibility in the appropriate health plan eligibility system.
Records carrier and group number if applicable.
Checks for previous prior authorization decisions.
Verifies coverage in member’s prescription benefit when necessary.
Verifies coverage in member’s health plan benefit when necessary.
Evaluates prescription claim history.
Reviews chart notes and/or lab values.
Identifies provider specialty when appropriate.
Applies medical policy criteria to prior authorization requests.
Evaluates whether request meets criteria for approval.
Reviews the request using professional clinical judgment on a case by case basisA pharmacist will review medication requests not addressed by p&t committee criteria or guidelines, develop and draft criteria for the non-formulary medication requested.
Researches and contributes drug references and clinical information to facilitate prior authorization review: directly to physicians via fax or phone encounter; or to pharmacy technicians via memo or on a personal level as an educational tool
Communicates with physicians regarding prior authorization:
O for a non-formulary drug
O plan benefits, exclusions
O quantity limits
O age restrictions
O formulary alternatives
Retrieves and collects data through available reporting resources (i.eDiscoverer, it department)
Compiles data for reporting purposes:
O drug utilization of non-formulary drugs
O overturned ips recommended denials
O audit pharmacy claims greater than $200.00
O suggest addition or deletion of drugs to/from the formulary
O updating qty/days or age limit ends
O support national p&t committee
O other tasks which may arise during the performance of any of the above mentioned duties
Our comprehensive benefits package:
Flexible work solutions including remote options, hybrid work schedules and dress flexibility
Competitive pay
Paid time off including paid holidays
Health insurance coverage for you and dependents
401(k) and stock purchase plans
Tuition reimbursement and best-in-class training and development
Education/experience:
Bachelor’s or doctorate of pharmacy degree.
One year prior experience.
License/certification:
Must have and maintain current, valid and unrestricted pharmacist license in the state of employment and credentialed by the health plan of employment.
For washington only: state pharmacist license must be obtained within six (6) months of hire.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are differentAll qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
