About Judi Health Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including: Capital Rx , a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers, Judi Health™ , which offers full-service health benefit management solutions to employers, TPAs, and health plans, and Judi® , the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform. Responsible for reviewing clinical coverage determination and appeals for different lines of business such as Commercial and Medicare. Knowledgeable in all aspects of coverage determination and appeals process and assist in meeting client expectations regarding efficiency and quality decision making.

Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity. Performs and handles inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations. ~ Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria. ~ Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers. ~ Make clinical prior authorization determinations in accordance with medical necessity and covered benefit guidelines within established turnaround times.



~ Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements. ~ Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies. ~ Deliver extraordinary customer care and service by responding to questions concerning customer accounts in a fast paced, structured environment within established time frames. ~ Active, unrestricted, pharmacist license required ~Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities ~ Have a designated workplace (an office, spare bedroom, etc.) Proficient in Microsoft Office Suite and experience using clinical resources (e.g. Micromedex, Lexicomp, Clinical Pharmacology) Remote, US Salary Range $This position description is designed to be flexible, allowing management the chance to assign or reassign duties and responsibilities as needed to best meet organizational goals.

Judi Health values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit 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. By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health.

📌 Appeals Pharmacist (temp-to-hire) (Vancouver)
🏢 Socket.dev
📍 Vancouver