Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. The Pharmacist/Clinician is an operation-based role that conducts criteria based & clinical review of medical data collected to perform prior authorization as per policy and procedure. The Pharmacist/Clinician will apply clinical knowledge to plan approved criteria for reviews of cases. This role will work from CVS Caremark supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Auth team and member services department, as well as provide on-call after hours availability for urgent PA request as needed. **Responsibilities** : 1.) Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design. Includes verifying insurance coverage and eligibility, interpreting clinical guideline criteria, consulting physicians and other healthcare providers, and appropriately utilizing clinical knowledge and resources while complying with department protocols. One of the crucial responsibilities is to guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals following agreed-upon approval & denial management processes. (60%) 2.) Collaborates with the technicians and prior authorization team members to process referrals, including answering clinical questions and collecting appropriate clinical/medical data needed to perform clinical assessments and reviews as per the health plan/employer-agreed criteria within the designated service level agreements. Performs and handles inbound and outbound phone calls with technicians, prior authorization team members, physicians, healthcare providers, and/or patients to facilitate prior authorization requests, answer inquiries, and/or resolve escalations. (25%) 3.) Maintains professional and technical knowledge of drug and disease states for the Specialty and Non-Specialty Pharmacy programs administered within the Commercial Prior Authorization and Case Review Unit (CRU) line of business. (10%) 4.) Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed. (5%) **Education** : Required: Bachelor’s Degree – BS Pharmacy and an active pharmacist license in the state of practice/residence. Preferred: Doctorate – Pharm D **Prior Work Experience** : Required :1 to 3 years Preferred: 3 to 5 years **Required Skills & Other Minimum Required Qualifications:** + Licensed Registered Pharmacist + Current experience within Caremark Case Review Unit (CRU) + Knowledge of Microsoft Office Suite: Excel and Word required; Access, Outlook, PowerPoint, Visio preferable. Keyboard skills essential. + Must be able to multitask and utilize multiple system applications simultaneously. + Must be able to utilize available resources independently and provide high quality work. + Must demonstrate problem solving ability and attention to detail. + Ability to adapt and change with workflow and shifting priorities. + Ability to work effectively in a team environment and provide mentorship to non-clinical staff on the PA team. + Must possess excellent written, verbal, grammar, and listening communication skills. + Must be able to effectively communicate with a diverse customer base (internal and external) in a friendly and confident manner. + Ability to maintain confidentiality of PHI (Protected Healthcare Information). + 1+ years CAS software experience + 1+ years AP400 software experience **Essential Functions** : 1. Regular and predictable attendance 2. Colleague will be required to work mandatory overtime/extended work week when needed 3. Colleague will be required to travel when needed 4. Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers. 5. Adhere to all policies and procedures 6. Attend ongoing training and development meetings **Physical Requirements:** 1. Sits at desk for long periods of time (up to 100%) 2. Talking on phone for extended periods of time (up to 100%) 3. Computer use for extended periods of time (100%) 4. Reading a computer screen (up to 100%) **Work Environment:** Work to be performed regularly in a CVS Health location or from an approved work-from-home location. **Pay Range** The typical pay range for this role is: $55.53 - $93.08 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies. For more detailed information on available benefits, please visit Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits) We anticipate the application window for this opening will close on: 01/10/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.