Appeals Pharmacist – Temp-to-Hire

About the role

The Appeals Pharmacist will evaluate clinical coverage determinations and appeals for commercial and Medicare lines of business. This temporary‑to‑hire position supports client expectations for efficient, high‑quality decision making within Judi Health’s pharmacy benefit management platform.

Key responsibilities

• Review and render coverage determinations for appeals based on clinical criteria and medical necessity.
• Handle inbound and outbound calls with physicians, providers, and patients to facilitate appeal requests and resolve escalations.
• Collaborate with internal and external Medical Directors, supplying clinical data for health‑plan reviews.
• Interpret clinical guidelines, conduct peer‑to‑peer reviews, and evaluate scientific literature to support decisions.
• Document prior‑authorization and appeal cases thoroughly and meet established turnaround times.
• Maintain quality, productivity, and compliance with HIPAA and internal SOPs.
• Deliver exceptional customer service in a fast‑paced environment.

Required profile

• Active, unrestricted pharmacist license.
• Minimum 1 year experience in prior‑authorization review or appeals.
• Strong ability to interpret clinical guidelines and medical necessity criteria.

Required skills

• Clinical guideline interpretation.
• Pharmaceutical literature evaluation.
• Prior‑authorization and appeals processing.
• Effective communication with healthcare providers.