Career Opportunities with Capital Rx

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Prior Authorization Pharmacist

Department: Prior Authorization & Customer

Location: Remote

Position Responsibilities:

  • Make clinical prior authorization and appeals determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times
  • Provide detailed and thorough documentation in prior authorization cases, overrides and call center cases
  • Perform peer-to-peer reviews with providers when requested
  • Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers
  • Effectively communicate issues and resolutions to members, pharmacies, providers, and appropriate internal stakeholders
  • Provide backup support to call center team as required
  • Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements
  • Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities
  • 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
  • Support staff training and development as required
  • 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
  • Provide support in clinical and claim reviews during various CMS and external audits
  • Collaborate with internal and external Medical Directors in administering appeals reviews
  • Responsible for the adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Minimum Qualifications:

  • Active, unrestricted, pharmacist license required
  • Bachelors or Doctor of Pharmacy Degree required
  • 2+ years of pharmacy experience required
  • 1+ year of Managed care or PBM pharmacy experience required
  • Proficient in Microsoft Office Suite with emphasis on Microsoft Excel
  • 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
  • Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities

Preferred Qualifications:

  • Medicare Part D Appeals experience preferred

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp™, Capital Rx is executing its mission through the deployment of JUDI®, the company’s cloud-native enterprise health platform, and a Single-Ledger Model™, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of 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.

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.

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