Prior Authorization Pharmacist

SpecialtyRx•Morton Grove, IL

About The Position

SpecialtyRx is a long-term care pharmacy providing pharmaceutical services to long-term care facilities, assisted living communities, and hospice providers. The Prior Authorization Pharmacist joins the Illinois Long-Term Care Pharmacy team and helps ensure patients receive timely access to prescribed medications by reviewing coverage requirements, supporting prior authorization submissions, resolving insurance claim rejections, and addressing reimbursement challenges. The pharmacist works with insurance providers, prescribers, long-term care facilities, hospice providers, and internal pharmacy teams on coverage restrictions, formulary requirements, medication approvals, and reimbursement issues. The role calls for strong clinical judgment and knowledge of pharmacy benefit plans, prior authorizations, insurance billing, and medication coverage reviews. Experience in long-term care pharmacy, hospice medication management, and Medicare Part D is preferred.

Requirements

Doctor of Pharmacy (Pharm.D.) or Bachelor of Science in Pharmacy from an accredited institution.
Active Illinois pharmacist license in good standing is required.
Knowledge of pharmacy claim rejection codes, formulary restrictions, coverage determinations, and insurance overrides.
Strong clinical assessment skills and ability to evaluate medication requests for appropriateness and medical necessity.
Excellent written and verbal communication skills with prescribers, insurance representatives, facility staff, and pharmacy colleagues.
Strong analytical, organizational, and problem-solving skills.
Proficiency in pharmacy management systems, electronic documentation, and Microsoft Office applications.
Ability to manage multiple authorization requests and prioritize urgent medication access needs in a fast-paced environment.
Ability to work independently and collaborate effectively with a multidisciplinary team.
Strong attention to detail, sound professional judgment, and commitment to patient safety and quality care.

Nice To Haves

Previous experience in pharmacy prior authorizations, insurance billing, utilization management, or medication coverage review.
Long-term care pharmacy experience.
Experience with hospice medication coverage and coordination.
Familiarity with Medicare Part D, Medicaid, commercial insurance plans, pharmacy benefit managers, and payer authorization requirements.

Responsibilities

Review medication orders and assess insurance coverage requirements, formulary restrictions, and prior authorization criteria.
Evaluate prior authorization requests for clinical appropriateness, medical necessity, and compliance with payer requirements.
Prepare, submit, and follow up on prior authorization requests to state-sponsored insurance plans, private insurers, Medicare Part D plans, and other applicable payers.
Review insurance claim rejections and determine appropriate clinical or administrative steps to resolve them.
Communicate with prescribers and healthcare providers to obtain supporting clinical information, documentation, and clarification.
Work with insurance companies and pharmacy benefit managers on medication coverage, overrides, rejected claims, and authorization status.
Research alternative coverage options and formulary alternatives for denied or restricted medications, collaborating with prescribers when clinically appropriate.
Prioritize time-sensitive authorization requests and communicate delays to appropriate parties.
Support medication coverage coordination for hospice patients, including researching payer requirements and addressing questions about hospice and non-hospice medications.
Collaborate with long-term care facilities, hospice teams, and internal pharmacy departments to resolve medication access and reimbursement issues.
Review patient insurance information and eligibility records to support accurate billing and claim processing.
Document authorization decisions, payer communications, clinical reviews, and follow-up activities in appropriate systems.
Assist with insurance audits, billing reviews, and outstanding authorization-related issues.
Maintain current knowledge of applicable pharmacy regulations, payer policies, formulary requirements, and prior authorization procedures.
Follow pharmacy policies, patient confidentiality requirements, and applicable federal and Illinois regulations.
Perform additional duties as assigned by pharmacy management.