RPh Advisor - Commercial Specialty

Responsibilities

• 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
• 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
• other healthcare professionals following agreed-upon approval & denial management processes. (60%) 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%) 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 Commercial Specialty line of business.
• Performs other related projects and duties as assigned, including attending training sessions and development meetings
• providing on-call and after-hours pharmacist availability as needed. (5%) This is a remote role open to qualified candidates within the United States.

Required

Required

• 1 to 3 years Preferred: 3 to 5 years Required Skills & Other Minimum Required Qualifications: Licensed Registered Pharmacist Current pharmacist experience within Caremark Commercial Specialty required Ability and willingness to work a flexible hourly schedule to include overtime, weekends, and holidays as needed 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 prior authorization 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).
• Essential Functions: Regular and predictable attendance Colleague will be required to work mandatory overtime/extended work week when needed to support business needs Colleague will be required to travel when needed Comply with departmental, company, state
• federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers.
• Adhere to all policies and procedures Attend ongoing training and development meetings Physical Requirements: Sits at desk for long periods of time (up to 100%) Talking on phone for extended periods of time (up to 100%) Computer use for extended periods of time (100%) Reading a computer screen (up to 100%) Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $50.48 - $84.62 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.
• Our people fuel our future.
• Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
• Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments .
• We anticipate the application window for this opening will close on: 07/13/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.