Pharmacist - Prior Authorization
We are seeking a licensed Pharmacist to join the Prior Authorization team and support clinical coverage determinations for pharmaceutical products. This role is responsible for reviewing prior authorization requests and making medical necessity and benefit coverage decisions in accordance with established pharmacy guidelines, prior authorization criteria, regulatory requirements, and sound clinical judgment. The Prior Authorization Pharmacist works independently when conducting clinical reviews and making coverage determinations, while collaborating with senior pharmacists, supervisors, and other members of the pharmacy team as needed.
Key Responsibilities
- Review and evaluate prior authorization and coverage determination requests for pharmaceutical products.
- Make clinical determinations regarding medical necessity and benefit coverage based on established criteria, pharmacy guidelines, plan requirements, and applicable regulations.
- Apply independent clinical judgment when reviewing member-specific clinical information and medication requests.
- Communicate with prescribing providers and other healthcare professionals to obtain additional clinical information or discuss coverage determinations when needed.
- Provide clinical support to the Customer Care Center regarding medication coverage, prior authorization requirements, and clinical inquiries.
- Collaborate with senior pharmacists, supervisors, and internal teams on complex or escalated cases.
- Support fraud, waste, and abuse monitoring and oversight activities as appropriate.
- Maintain knowledge of pharmacy industry trends, clinical guidelines, new therapies, and regulatory changes.
- Stay current on operational procedures, customer-specific requirements, and reference materials.
- Maintain accurate and timely documentation of clinical reviews and determinations.
- Meet established quality, productivity, accuracy, and turnaround-time expectations.
Qualifications
- Current, active Pharmacist license required.
- Bachelor’s degree in Pharmacy required; PharmD preferred.
- Prior professional pharmacist experience is not required.
- Prior experience with prior authorization, pharmacy benefit management, utilization management, or coverage determinations is preferred.
- Strong clinical judgment and ability to interpret clinical documentation and medication-related information.
- Strong written and verbal communication skills.
- Ability to work independently while collaborating effectively within a team environment.
- Strong attention to detail and ability to work within established clinical and regulatory guidelines.
- Proficiency with Microsoft Windows-based systems and general PC applications.