Medical Reviewer, Pharmacist
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Job Description
Medical Reviewer (Pharmacist) supporting Gainwell Technologies’ California healthcare programs. Reviewing pharmacy claims, drug authorizations, utilization, rebates, and clinical documentation remotely.
Responsibilities:
- Perform pharmacy and medication-related clinical reviews
- Support pharmacy claim review and adjudication activities
- Provide clinical expertise for drug utilization review and drug-related authorization requests
- Support drug rebate and pharmacy program activities as assigned
- Review pharmacy documentation for compliance with applicable policies and coverage requirements
- Provide technical expertise and assistance related to pharmacy review
- Document findings and recommendations accurately and timely
- Collaborate with physicians, nurses, pharmacy teams, operations, and other healthcare professionals
- Maintain knowledge of applicable pharmacy policies and regulatory requirements
- Work primarily from a home office while supporting Medical Review Services for California healthcare programs
- Review pharmacy, clinical, claim, authorization, and supporting documentation
- Navigate multiple computer systems and applications to complete reviews and document findings
- Meet established quality, accuracy, productivity, and turnaround-time expectations
Requirements:
- Current, non-expired pharmacist license from the State of California, in good standing
- Must not be under suspension from Medicare, Medicaid, or pharmacy practice in California
- Must not have been previously sanctioned for fraud or abuse
- Three (3) years of previous experience as a pharmacy consultant for a government or private-sector healthcare payer; or one (1) year of MMIS experience in a large state providing technical expertise and assistance for pharmacy review
- Strong oral and written communication skills
- Strong knowledge of pharmacy practices, medication review, and healthcare reimbursement processes
- Maintain all professional licenses, certifications, and credentials required for the position in active, unrestricted, and good-standing status
- Travel requirement: 0-10%
Benefits:
- Flexible vacation policy
- 401(k) employer match
- Comprehensive health benefits
- Educational assistance
- Leadership and technical development academies
- Flexible work hours
- Remote work environment
- Ongoing training and support
- Work-life balance
- Career development opportunities
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