Prior Authorization Pharmacist (MUST HAVE 3+ YEARS IN PBM OR ADJACENT)

DisclosedRx

10d

About The Position

The Prior Authorization Pharmacist is a licensed clinical professional responsible for reviewing, evaluating, and making coverage determinations for medication prior authorization (PA) requests in accordance with DisclosedRx policies, clinical guidelines, and regulatory requirements. This role ensures safe, appropriate, and cost-effective medication use while supporting members, providers, and operational teams through timely and accurate clinical decision-making. Success in this role requires strong clinical judgment, a deep understanding of pharmacy benefit management, and the ability to apply evidence-based criteria to complex medication requests. The Prior Authorization Pharmacist works collaboratively with internal teams to support operational efficiency, clinical accuracy, compliance, and continuous improvement within a rapidly growing PBM environment.

Requirements

Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy from an accredited institution.
Active, unrestricted U.S. pharmacist license.
3+ years of experience in prior authorization, utilization management, PBM, managed care, or payer pharmacy operations.
Strong understanding of drug therapy, clinical guidelines, specialty medications, and formulary management.
Excellent analytical, clinical decision-making, and documentation skills.
Proficiency in pharmacy benefit systems, prior authorization platforms, and electronic documentation.
Strong written and verbal communication skills.
Ability to manage multiple priorities and perform in a fast-paced environment with strict timelines.
High level of integrity and ability to handle confidential or sensitive clinical information.

Nice To Haves

Multi-state pharmacist licensure.
Experience reviewing specialty medications, biologics, or complex therapy classes.
Prior PBM or health plan experience.
Experience with clinical criteria development, formulary management, or utilization management programs.
Familiarity with claims systems, PA automation tools, or pharmacy informatics.

Responsibilities

Reviews prior authorization requests for formulary and non-formulary medications, applying clinical criteria, utilization management policies, FDA-approved indications, and evidence-based guidelines.
Makes approval, denial, or modification determinations within defined turnaround times and scope of licensure.
Documents clinical rationale, request details, communications, and outcomes accurately within internal systems.
Communicates determinations professionally to providers, pharmacies, and internal stakeholders.
Identifies clinically appropriate alternatives, step-therapy substitutions, or cost-effective options as applicable.
Collaborates with the Clinical Services team to ensure consistency and quality of PA decisions.
Supports operational workflows by assisting with escalated clinical questions, benefit interpretation, and guideline clarification.
Ensures compliance with federal and state regulatory requirements, accreditation standards, and internal policies.
Participates in policy review, clinical criteria updates, and development of utilization management strategies.
Provides clinical expertise to support formulary management, analytics, operations, and client-specific program requirements.
Assists with training and development of staff on clinical criteria, drug classes, and PA workflows.
Supports quality assurance processes, audits, and continuous improvement initiatives to enhance accuracy and efficiency.
Performs other duties as assigned or requested. Any one position may not include all the duties listed; these duties represent the key responsibilities typically associated with this role.