Prior Authorizations Pharmacist

Responsibilities

• Review and evaluate prior authorization requests in accordance with member benefit plans and clinical guidelines
• Identify opportunities for therapeutic optimization and cost-effective medication management
• Coordinate the clinical review of appeals related to pharmacy benefit determinations
• Communicate coverage decisions and clinical rationale to providers and members
• Assist in the development and maintenance of prior authorization criteria and clinical guidelines
• Analyze pharmacy utilization data to identify prescribing trends and cost savings
• Provide clinical leadership and mentorship to clinical associates
• Ensure compliance with HIPAA and accreditation standards

Requirements

• Bachelor of Science in Pharmacy (BSPharm) or Doctor of Pharmacy (Pharm.D.) degree
• Active, current, and unrestricted Pharmacist license
• Minimum of one year of direct prior authorization or utilization management experience
• Experience applying evidence-based clinical guidelines in pharmacy practice

Preferred Qualifications

• Pharmacy Benefit Management (PBM) experience
• Experience reviewing pharmacy prior authorizations and appeals
• Experience with formulary management and drug utilization review (DUR)
• Experience supporting NCQA or URAC accreditation standards

Benefits

• 401(k) with matching
• Dental insurance
• Health insurance
• Vision insurance
• Health savings account
• Paid time off