PRN Pharmacist Reviewer – Medicare Part D Formulary Criteria Review

Rainmakers Strategic Solutions•, (Multiple States)

5d•Remote

About The Position

Rainmakers Strategic Solutions is seeking PRN pharmacists to support its contract with the Centers for Medicare & Medicaid Services (CMS), reviewing prior authorization (PA) and step therapy (ST) criteria submitted by Medicare Part D plan sponsors for approval. Pharmacist Reviewers assess plan-level criteria across multiple plans and formularies—not patient-level prior authorizations—against CMS guidance in Chapter 6 of the Medicare Prescription Drug Benefit Manual, FDA-approved labeling, recognized Part D compendia, and widely accepted treatment guidelines. They determine whether each criteria element is approvable and write clear, specific comments explaining deficiencies. The position requires strong knowledge of Medicare Part D requirements and utilization management principles, sound clinical judgment, and accurate, consistent reviews within fixed CMS deadlines. It is a US-based, fully remote, PRN position with a seasonal workload. Peak demand runs June through November, with approximately 20 hours per week expected during peak season. Outside peak season, monthly reviews typically conclude by the second or third week of each month, with an estimated 10–15 hours per month. Extended hours may be required to meet deadlines.

Requirements

Doctor of Pharmacy degree from an accredited college or university.
Current, active, unrestricted license to practice pharmacy in the United States.
At least five years of experience in clinical pharmacy, formulary management, utilization management, pharmacy benefit management, or Medicare Part D.
Advanced knowledge of Medicare Part D coverage requirements and utilization-management programs, including Chapter 6 of the Medicare Prescription Drug Benefit Manual.
Strong understanding of FDA-approved versus medically accepted (compendia-supported) indications and their application to coverage criteria.
Strong clinical background and demonstrated ability to review, interpret, and apply treatment guidelines and evidence-based literature.
Proficiency with Micromedex DrugDex, AHFS Drug Information, NCCN Clinical Practice Guidelines, Clinical Pharmacology, Lexi-Drugs, and other drug information resources.
Strong written communication skills, including the ability to write concise, precise, grammatically correct findings for a regulatory audience.
Ability to apply review criteria consistently and accurately across large volumes of criteria while meeting fixed deadlines.
Strong analytical, critical-thinking, problem-solving, and decision-making skills.
Ability to work independently with minimal supervision while meeting established productivity and quality expectations.
Comfort working in structured databases and data-driven review tools such as Microsoft Access or SQL.
Proficiency in Microsoft Office, including Teams, Word, Excel, Outlook, and SharePoint.
Availability of approximately 20 hours per week during peak season is expected; an estimated 10–15 hours per month are expected outside peak season.
Extended hours may be required to meet review deadlines.

Nice To Haves

Experience developing or reviewing PA and ST criteria for a Part D plan sponsor, pharmacy benefit manager, or Pharmacy and Therapeutics (P&T) committee.
Pharmacy residency or board certification.

Responsibilities

Review sponsor-submitted PA and ST criteria for compliance with Chapter 6 of the Medicare Prescription Drug Benefit Manual and related CMS guidance during the three-phase annual review and monthly reviews of new or updated criteria.
Evaluate PA criteria fields—including indication indicator, off-label uses, exclusion criteria, required medical information, age and prescriber restrictions, coverage duration, other criteria, and prerequisite therapy—for consistency with FDA-approved labeling, recognized Part D compendia, and widely accepted treatment guidelines.
Evaluate ST criteria to determine whether prerequisite drugs are clinically appropriate, account for all indications of the stepped drug, follow on-label versus off-label standards, and avoid excessive prerequisite-drug counts or durations.
Apply CMS review principles for Part B versus Part D step therapy, indication-based formulary design, over-the-counter step therapy prerequisites, and synchronization of criteria with the submitted formulary file.
Support utilization-management reviews for Medicare drugs selected for negotiation under the Inflation Reduction Act; identify more restrictive PA or ST applied to a selected drug than to formulary alternatives in the same class and evaluate sponsor justifications.
Write clear, specific, consistent comments to sponsors for each failed criteria element, using standard language for recurring concerns and identifying every issue so sponsors can make corrections.
Review resubmitted criteria, formulary files, and clinical justifications to determine whether revisions address previously communicated concerns.
Apply consistent pass/fail decisions and comments to identical criteria across formularies, using criteria identification codes and established decision precedents.
Use drug information resources, including Micromedex DrugDex, AHFS Drug Information, NCCN Clinical Practice Guidelines, Clinical Pharmacology, and Lexi-Drugs, to evaluate the clinical basis of submitted criteria.
Interpret and apply federal Medicare Part D statutes, regulations, and CMS guidance related to formulary and utilization-management review.
Maintain current knowledge of CMS Part D policy, new drug approvals and indications, drug safety updates such as new boxed warnings, and changes in treatment guidelines.