Prior Authorization Clinical Pharmacist
About The Position
The Prior Authorization Clinical Pharmacist evaluates and manages the selection and utilization of pharmaceuticals to support safe, effective, and cost-efficient medication use. The role supports clinical pharmacy programs, including Drug Utilization Review (DUR), Drug Information Services (DIS), and formulary management. This position researches and synthesizes clinical pharmaceutical data; prepares and presents therapeutic class reviews and drug monographs to the Pharmacy and Therapeutics (P&T) Committee; and may review and approve or deny pharmaceutical coverage based on medical necessity criteria, as permitted by applicable laws and program contracts. The pharmacist also serves as a clinical resource to other pharmacists, provides guidance on therapeutic interventions and dosage conversions, prepares information for network physicians, and communicates evidence-based medication recommendations to physicians and clinical teams. The role is described as virtual full-time, except for required in-person training. Candidates must live within a reasonable commuting distance of a posting location unless an accommodation is granted. Utilization review or appeals consideration must be conducted from a U.S. state or territory, subject to the stated legal exceptions.
Requirements
- Bachelor of Arts or Bachelor of Science in Pharmacy.
- At least 2 years of managed care pharmacy (PBM) experience, or a residency in lieu of work experience, or an equivalent combination of education and experience.
- Registered pharmacist.
- Current unrestricted pharmacist license in applicable state(s).
- For associates in Puerto Rico who are member- or patient-facing in a clinical setting or in the Best Transportation unit: current Puerto Rico health certificate and current Puerto Rico Law 300 certificate.
- When conducting utilization review or appeals consideration, must be located in a U.S. state or territory, unless expressly allowed by applicable law or regulation; cannot be located on a U.S. military base, vessel, or embassy unless participating in command-sanctioned activities.
- For URAC-accredited areas: strong oral, written, and interpersonal communication, problem-solving, facilitation, and analytical skills.
Nice To Haves
- Active, unrestricted Registered Pharmacist license in Kansas, North Carolina, and/or Washington.
- PharmD.
- PBM experience.
- Prior Authorization experience.
- Specialty Medication experience.
Responsibilities
- Research and synthesize detailed clinical data related to pharmaceuticals.
- Prepare and present therapeutic class reviews and drug monograph information to the Pharmacy and Therapeutics Committee.
- Review and approve or deny pharmaceutical coverage based on medical necessity criteria when permitted by applicable law or program contracts.
- Coordinate coverage decisions with internal stakeholders or health plan medical directors as needed.
- Serve as a clinical resource to other pharmacists on prospective, inpatient, and retrospective Drug Utilization Reviews.
- Provide dosage conversion and clinical support for therapeutic interventions.
- Prepare information for network physicians.
- Provide clinical guidance for therapeutic interventions, dosage conversions, and evidence-based medication use.
- Develop and communicate drug information and recommendations to network physicians and clinical teams.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs, unless covered by a collective bargaining agreement
- Medical benefits
- Dental benefits
- Vision benefits
- Short- and long-term disability benefits
- 401(k) with matching
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
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What This Job Offers
Job Type
Full-time
