NEW JOB OPENING
PHARMACIST PRIOR AUTHORIZATION CLINICAL REVIEW
IN Remote, USA!

Required Education

• Bachelor’s degree in pharmacy (BS Pharmacy)



Preferred Education

• Doctorate in Pharmacy (PharmD)



Required License/Certification

• Active pharmacist license in the state of residence



Required Qualifications/Skills/Experience

• 1–3 years of prior work experience as a pharmacist

• 2 years in prior authorization

• Ability to evaluate and review prior authorization requests using clinical criteria and plan design

• Ability to interpret clinical guideline criteria and apply clinical knowledge and resources appropriately

• Ability to collaborate with physicians, healthcare providers, technicians, prior authorization team members, patients, health plans, and employers

• Ability to collect and evaluate appropriate clinical and medical data

• Ability to handle inbound and outbound calls and resolve escalations

• Ability to meet designated service level agreements (SLAs)

• Ability to comply with department protocols and approval and denial management processes

• Basic computer skills



Preferred Qualifications/Skills/Experience

• 3–5 years of prior work experience in prior authorization

• Previous pharmacy experience in a pharmacy benefit manager (PBM) environment

• Knowledge of drug and disease states for Specialty and Non-Specialty Pharmacy programs



Pharmacist Overview

• The Pharmacist/Clinician is an operations-based role responsible for conducting criteria-based and clinical reviews of medical data to perform prior authorization determinations in accordance with established policies and procedures

• Applies clinical knowledge and approved criteria to review cases and make appropriate coverage determinations

• Works within supported pharmacy and clinical systems to review pending prior authorizations and communicate with physicians, healthcare providers, and members regarding approved or denied requests

• Collaborates with the Prior Authorization team and Member Services to answer clinical questions, obtain necessary medical information, and resolve escalations

• Maintains professional and technical knowledge of drug and disease states across Specialty and Non-Specialty Pharmacy programs

• Provides on-call and after-hours pharmacist availability for urgent prior authorization requests as needed



Job Duties

• Evaluate and review all prior authorization requests and render coverage determinations based on clinical criteria and plan design

• Verify insurance coverage and eligibility and interpret applicable clinical guideline criteria

• Consult with physicians and other healthcare providers as needed and appropriately utilize clinical knowledge and resources while complying with department protocols

• Communicate case decisions promptly and efficiently to healthcare providers, health plans/employers, patients, and other healthcare professionals in accordance with established approval and denial management processes

• Collaborate with technicians and Prior Authorization team members to process referrals

• Answer clinical questions and collect appropriate clinical and medical data needed to perform clinical assessments and reviews according to health plan/employer-agreed criteria and designated SLAs

• Handle inbound and outbound phone calls with technicians, Prior Authorization team members, physicians, healthcare providers, and patients to facilitate prior authorization requests, answer inquiries, and resolve escalations

• Maintain professional and technical knowledge of drug and disease states for Specialty and Non-Specialty Pharmacy programs administered within the Commercial Specialty line of business

• Attend training sessions and development meetings

• Provide on-call and after-hours pharmacist availability as needed

• **Only those lawfully authorized to work in the designated country associated with the position will be considered.**

• **Please note that all Position start dates and duration are estimates and may be reduced or lengthened based upon a client’s business needs and requirements.**