Role Description A confidential managed care organization is seeking an experienced Appeals Pharmacist to review, evaluate, and process medication coverage appeals. This role is ideal for pharmacists who want to leverage their clinical knowledge and critical thinking skills to advocate for patients and ensure fair, evidence-based decisions. - Review clinical documentation for medication coverage appeals and grievances. - Apply evidence-based guidelines, plan policies, and regulatory requirements to determine outcomes. - Prepare written clinical rationales to support appeal determinations. - Collaborate with physicians, nurses, and medical directors during case reviews. - Track, document, and report appeal outcomes in compliance with state and federal regulations. - Support process improvements to enhance timeliness and quality of appeal decisions. Qualifications - Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy degree. - Active and unrestricted pharmacist license in the U.S. - Prior managed care or utilization management experience preferred — retail and hospital pharmacists with strong clinical and documentation skills are encouraged to apply. - Excellent clinical judgment, written communication, and attention to regulatory detail. Requirements - Play a critical role in ensuring patients get fair access to necessary medications. - Gain expertise in appeals, utilization management, and managed care pharmacy. - Many roles offer hybrid or fully remote options. - Competitive salary, comprehensive benefits, and opportunities for advancement. Company Description We are a confidential healthcare partner working with health plans and managed care organizations nationwide. Our appeals pharmacists safeguard patient access while ensuring compliance with all regulatory standards. Apply Today Join our team as an Appeals Pharmacist and help ensure every patient receives a fair review of their medication needs.

• Support patients on anticoagulation therapy across Colorado and Montana • Facilitate medication access by helping resolve barriers • Collaborate with pharmacists and advanced practice providers to ensure safe and high-quality care • Coordinate lab monitoring and assist with adherence to provider recommendations • Manage applications for home monitoring devices and related services • Perform clinic administrative tasks, including scheduling visits and handling phone calls

• Support standardization and optimization of specialty pharmacy services across Bon Secours Mercy Health • Ensure proper processing and problem solving of specialty medications and other medications supported by pharmacy • Provide excellent customer service via phone and occasional direct patient contact • Receive patient prescriptions, review medication list with patients, answer phones, and triage phone calls • Help maintain the pharmacy in proper order and ensure accurate billing of third-party payer plans • Assist patients in receiving medications at the lowest cost and facilitate third party billing • Work closely with patients, providers, and the specialty pharmacy team

• Collaborates with the technicians and prior authorization team members to process referrals • Evaluate and review all prior authorization requests and render coverage determinations • Guarantee that the decisions regarding cases are conveyed promptly and efficiently to all the healthcare providers, health plans/employers, patients, and other healthcare professionals • Performs and handles inbound and outbound phone calls to facilitate prior authorization requests • Establishes and maintains communication among CVS Caremark, health plan, and employer group staff • Maintains professional and technical knowledge of drug and disease states • Performs other related projects and duties as assigned