In this role, you will leverage your clinical expertise to perform prospective and retrospective coverage reviews, including prior authorizations and appeals, for both self‑administered and provider‑administered medications. You will apply evidence‑based clinical criteria along with state and federal regulatory requirements to ensure accurate, well‑supported coverage determinations and denial rationales.
As a key clinical resource, you’ll collaborate within a knowledgeable and highly organized team environment while working independently to apply sound clinical judgment. The ideal candidate brings a strong background in prior authorization decisioning and coverage reviews, with prior experience using NovoLogix or MHK systems is highly preferred. A solid understanding of regulatory and accreditation guidelines—including FDA, NCQA, EQRO, and CMS requirements—is required. This role is well suited for a pharmacist who values autonomous work, clinical rigor, regulatory compliance, and the opportunity to make a meaningful impact on patient access to care.
Note:
• Must be available for weekend on call shifts that occur every few weeks.
• Although we are based in Chattanooga, TN, this is a fully remote role.
• Sponsorship is not available for this position.
• At BCBST, we foster a culture where innovation is encouraged, including the responsible use of AI-enabled tools to support everyday work. As roles become more advanced, employees are expected to leverage AI, guided by established workflows, templates, and policies, to improve how we serve our members.
Job Duties & Responsibilities
- Performs prospective and retrospective coverage reviews and appeals per State and Federal regulations.
- Serves as a clinical resource to aid in solving basic to mid-level reviews with limited assistance and supervision.
- Maintains denial rationale associated with clinical criteria and ensures that decision letters meet regulatory compliance and guidance.
- Participates in alternating team on-call rotation.
Job Qualifications
Education
- Doctor of Pharmacy (PharmD) Degree
Experience
- 3 years - Clinical experience required, and/or completion of 1 year residency and/or board certification
Skills\\Certifications
- Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
- Competency in compendia navigation and research
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Must be a team player, be organized and able to to handle multiple projects
- Excellent oral and written communication skills
- Strong interpersonal and organizational skills
- Solid understanding of regulatory guidelines (FDA, NCQA, EQRO, CMS) required
- Knowledge of medical and pharmacy products
License
- Licensed in Tennessee to practice Pharmacy, or eligible for licensure in the state of Tennessee to practice Pharmacy within 120 days of employment
Number of Openings Available
1
Worker Type:
Employee
Company:
BCBST BlueCross BlueShield of Tennessee, Inc.
