Appeals Pharmacist (temp-to-hire)

About this role

About Judi Health Judi Health is a health technology company providing benefit administration solutions to employers, unions, health plans, and government entities. Judi Health replaces fragmented, outdated systems with the industry's first Unified Claims Processing™ architecture, seamlessly consolidating pharmacy and medical benefit administration on a single, secure platform. By delivering true price transparency, eliminating unnecessary middleman fees, and leveraging advanced AI-powered care delivery, Judi Health helps clients achieve unprecedented operational efficiency and service levels.

At Judi Health, we're deploying the infrastructure our country needs to deliver the healthcare we all deserve. We are the intelligence platform powering benefits plans for millions of Americans and proudly leading the next generation of care. To learn more, visit www.judi.health . Position Summary: 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. Position Responsibilities: 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. Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals. Perform peer to peer reviews with providers when requested. Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers.

Provide detailed and thorough documentation in prior authorization cases, appeals cases, and overrides. 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. Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.