At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. **POSITION SUMMARY** : The RPh Operations Advisor is an operation-based role that conducts criteria based & clinical review of medical data collected to perform prior authorization as per policy and procedure. The RPh Operations Advisor will apply clinical knowledge to plan approved criteria for reviews of cases. This role will work from CVS Caremark supported systems and take inbound calls from physicians or members regarding their pending, approved, or denied prior authorizations, internally support the Prior Auth team and member services department, as well as provide on-call after hours availability for urgent PA request as needed. **PRIMARY DUTIES AND RESPONSIBILITIES** : 1. 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, and 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, and other healthcare professionals following agreed-upon approval & denial management processes. 2. 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. 3. 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 Case Review Unit (CRU) line of business. 4. Performs other related projects and duties as assigned, including attending training sessions and development meetings, and providing on-call and after-hours pharmacist availability as needed. **EDUCATION** **:** Required: Bachelor's Degree - BS Pharmacy and an active pharmacist license in the state of practice/residence. Preferred: Doctorate - Pharm D **PRIOR WORK EXPERIENCE** Required: 1 to 3 years Preferred: 3 to 5 years **REQUIRED SKILLS & OTHER MINIMUM REQUIRED QUALIFICATIONS:** + Licensed Registered Pharmacist + **Current pharmacist experience within Case Review Unit (CRU)** + 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 PA 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:** 1. Regular and predictable attendance 2. Colleague will be required to work mandatory overtime/extended work week when needed to support business needs 3. Colleague will be required to travel when needed 4. Comply with departmental, company, state, and federal requirements when processing all information to ensure accuracy of information being provided to internal and external customers. 5. Adhere to all policies and procedures 6. Attend on going training and development meetings Physical Requirements: 1. Sits at desk for long periods of time (up to 100%) 2. Talking on phone for extended periods of time (up to 100%) 3. Computer use for extended periods of time (100%) 4. Reading a computer screen (up to 100%) 5. Light lifting of less than 10 lbs **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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: + **Affordable medical plan options,** a **401(k) plan** (including matching company contributions), and an **employee stock purchase plan** . + **No-cost programs for all colleagues** including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. + **Benefit solutions that address the different needs and preferences of our colleagues** including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 07/28/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.