Clinical Pharmacist

This is a fully remote position, open to applicants in Florida.

📋 Description

• Process and evaluate prior authorization requests for non-formulary medications to ensure clinical suitability.

• Review finalized prior authorization requests along with recommended denials from pharmacy technicians, formulary alternatives, comments, and attachments.

• Verify member identification, date of birth, eligibility, carrier, and group information.

• Assess previous prior authorization decisions and confirm prescription and health plan benefit coverage.

• Analyze prescription claim history, chart notes, lab values, provider specialty, and medical policy criteria.

• Use professional clinical judgment to determine if requests meet approval criteria on a case-by-case basis.

• Examine medication requests not covered by P&T Committee criteria or guidelines and create and draft criteria.

• Research and provide drug references and clinical information for prior authorization assessments.

• Communicate with physicians and pharmacy technicians regarding non-formulary drugs, benefits, exclusions, quantity limits, age restrictions, and formulary alternatives.

• Gather, collect, and compile data for reporting purposes.

• Audit pharmacy claims exceeding $200.00.

• Recommend changes to the formulary and update quantity/day or age-limit entries.

• Assist the National P&T Committee.

• Perform other related duties as required.

⛳️ Requirements

• Must be legally authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.

• Bachelor’s or Doctorate of Pharmacy degree is required.

• A minimum of one year of prior experience is necessary.

• Current, valid, and unrestricted Pharmacist license in the state of employment must be obtained and maintained.

• Credentialing by the health plan of employment is required.

• Additional state licensure may be necessary based on business requirements.

• Experience in managed care, utilization management, prior authorization, or health plan pharmacy operations is preferred.

• Willingness to participate in periodic weekend and holiday coverage rotations.

• Strong clinical pharmacy knowledge and professional clinical judgment are essential.

• Capability to review chart notes, lab values, prescription claim history, benefits, and formulary criteria.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement programs.

• Paid time off along with holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.

• Additional incentives may be part of the total compensation package.

• Commitment to equal opportunity and diversity.