Judi Health is seeking an Appeals Pharmacist to join our team. In this role, you will be responsible for reviewing clinical coverage determinations and appeals for different lines of business, including Commercial and Medicare. You will use your clinical expertise to ensure efficient, high-quality decision-making that meets our clients' expectations.
What You'll Do
- Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity.
- Perform inbound and outbound phone calls with physicians, healthcare providers, and patients to facilitate appeals, answer inquiries, and resolve escalations.
- Collaborate with internal and external Medical Directors by providing necessary clinical data for reviews per health plan criteria.
- Interpret clinical guideline criteria and utilize clinical knowledge to render approvals and denials on all appeal levels.
- Conduct peer-to-peer reviews with providers upon request.
- Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decisions and recommendations.
- Provide detailed documentation in prior authorization cases, appeals cases, and overrides.
- Make clinical prior authorization determinations in line with medical necessity and benefit guidelines within established turnaround times.
- Maintain quality and productivity standards for all cases while meeting turnaround time requirements.
- Stay current on all communications and updated processes from multiple channels and apply them daily.
- Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
- Deliver extraordinary customer care by responding to account questions in a fast-paced, structured environment within set time frames.
- Adhere to the company Code of Conduct, including reporting noncompliance.
What We're Looking For
- Active, unrestricted pharmacist license.
- 1+ years of prior authorization review or appeals experience.
- Ability to work independently with minimal supervision and stay productive in a remote, high-volume, metric-driven environment with shifting priorities.
- A designated, secure workplace (e.g., office, spare bedroom) with a closed door, protected from disruptive noise.
- Strong oral and written communication skills.
- Proficiency in Microsoft Office Suite and experience using clinical resources like Micromedex, Lexicomp, or Clinical Pharmacology.
Nice to Have
- Experience working with Medicare appeals.
Technical Stack
- Microsoft Office Suite
- Clinical resources (e.g., Micromedex, Lexicomp, Clinical Pharmacology)
Benefits & Compensation
- Salary range: $120,000 - $130,000 USD
Work Mode
This is a fully remote position.
Judi Health values a diverse workplace and celebrates the diversity that each employee brings to the table. Judi Health provides equal employment opportunities to all employees and applicants and prohibits 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.
