Judi Health
Healthcare
AppealsPharmacist(temp-to-hire)
Neural analysis suggests this role is
optimal for Mid+ candidates.
“Appeals Pharmacist (temp-to-hire) at Judi Health. Skills: Pharmacist license, Appeals review, Clinical criteria interpretation. Evaluate and review all appeals requests. Render coverage determinations”
What You'll Achieve.
Meet client expectations regarding efficiency and quality; Meet established turnaround time requirements; Maintain quality and productivity standards
Industry & Context.
Clinical decision making
Designated secure workplace, Closed door office
What They're Looking For.
Must Have
Active, unrestricted, pharmacist license, 1+ years prior authorization review or appeals experience, Ability to work independently, Proficient in Microsoft Office Suite, Experience using clinical resources
Nice to Have
Experience working with Medicare appeals
What You'll Do.
Evaluate and review all appeals requests
Render coverage determinations
Perform and handle inbound and outbound phone calls
Facilitate appeal requests
Collaborate with Medical Directors
Provide appropriate clinical/medical data
Interpret clinical guideline criteria
Utilize clinical knowledge and resources
Render approvals and denials
Perform peer to peer reviews
Perform scientific literature evaluation
Support decision-making and recommendations
Provide detailed and thorough documentation
Make clinical prior authorization determinations
Maintain quality and productivity standards
Meet established turnaround time requirements
Remain current on all communications
Apply updated processes to daily responsibilities
Follow all internal Standard Operating Procedures
Adhere to HIPAA guidelines and policies
Deliver extraordinary customer care and service
Respond to questions concerning customer accounts
Adherence to Capital Rx Code of Conduct
How You'll Work.
Communication Scope
Oral communication; Written communication
Full Job Description
About Judi Health Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including: Capital Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers, Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform. Together with our clients, we’re rebuilding trust in healthcare in the U. S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.judi.health. Position Summary: Responsible for reviewing clinical coverage determination and appeals for different lines of business such as Commercial and Medicare. Knowledgeable in all aspects of coverage determination and appeals process and assist in meeting client expectations regarding efficiency and quality decision making. Position Responsibilities: Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity. Performs and handles inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations. Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria. Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals. 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. Provide detailed and thorough doc
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