Prior Authorization Pharmacist

Soleo Health Inc•Frisco, TX

4d•Remote

About The Position

The Prior Authorization Pharmacist performs comprehensive clinical reviews and manages prior authorization requests for specialty pharmacy and infusion therapies. This role ensures timely and accurate approval by assessing clinical documentation, applying payer-specific medical necessity criteria, and communicating directly with Pharmacy Benefit Managers (PBMs) and health plans. The pharmacist also supports denial prevention and resolution by engaging PBMs in real time to address rejections, preparing evidence-based appeals as needed, and collaborating with internal teams to enhance patient access to therapy.

Requirements

Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy from an accredited institution.
Active, unrestricted U.S. pharmacist license.
2+ 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.
Must be able to communicate effectively with all levels of organization within Soleo Health.
Must enthusiastically support Soleo Health’s philosophy and goals.

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.
Competent in the use of Word, Excel, and Power Point

Responsibilities

Conduct comprehensive clinical reviews for specialty pharmacy and infusion therapy prior authorization requests to ensure appropriateness, accuracy, and completeness.
Evaluate clinical documentation against payer-specific medical necessity criteria, coverage policies, and clinical guidelines.
Prepare, submit, and track prior authorization requests to Pharmacy Benefit Managers (PBMs) and health plans to ensure timely determinations.
Communicate directly with PBMs and health plans to clarify clinical information, respond to requests for additional documentation, and resolve authorization issues.
Proactively mitigate denials by addressing rejections in real time through live outreach to PBMs and payers. Create and submit evidence-based appeal letters, including clinical rationale, literature support, and policy alignment, as needed.
Collaborate with patient access team, and other internal stakeholders to obtain required documentation and optimize patient access to therapy.
Monitor authorization outcomes and track performance metrics to identify delays, barriers, or trends impacting patient access.
Stay current with evolving payer policies, clinical guidelines, and regulatory requirements affecting specialty pharmacy and infusion services.
Identify opportunities for workflow and training optimization and contribute to process improvement initiatives aimed at improving efficiency, compliance, and patient access.