Clinical Review Pharmacist – 6-month, Full-time Contract

This is a fully remote position, open to applicants in Alabama, +46 more states.

📋 Description

• Assess and make prompt, evidence-based determinations on prior authorizations and appeals utilizing clinical guidelines and benefit criteria

• Ensure adherence to federal, state, and internal regulations across relevant business lines

• Precisely document clinical decisions and maintain comprehensive records in line with regulatory and accreditation (URAC/NCQA) utilization review standards

• Provide assistance to members, prescribers, and pharmacies by addressing clinical inquiries

• Remain updated with clinical prescribing guidelines, internal policies, and regulatory modifications

• Follow established internal processes, job aids, and HIPAA regulations to safeguard patient privacy and data security

• Recognize and report potential fraud, waste, and abuse (FWA)

• Aid in the training and development of both new and existing team members

• Support leadership with special projects, process enhancements, and operational initiatives

⛳️ Requirements

• Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy (B.S. Pharm) from an ACPE-accredited pharmacy school

• Active, unrestricted pharmacist license in the state of residence

• At least 2 years of experience in pharmacy practice

• Excellent communication, writing, and organizational abilities

• Capacity to handle multiple priorities in a fast-paced, metric-focused environment

• Basic understanding of drug information, clinical guidelines, formulary design, and utilization management tactics

• Flexible and adaptable to changes

• Availability to work evenings, weekends, and holidays on a rotating or fixed schedule

• Preferred: One year of experience in prior authorization or utilization management

• Preferred: One year of experience in managed care or pharmacy benefit management (PBM)

• Preferred: Hands-on experience conducting prior authorization reviews, clinical appeals, formulary exceptions, step therapy evaluations, and quantity limit reviews

• Preferred: Familiarity with Google Workspace (Gmail, Docs, Sheets, and Drive)

🏝️ Benefits

• Time off programs

• Medical insurance

• Dental insurance

• Vision insurance

• Mental health support

• Paid parental leave

• Life insurance

• Disability insurance

• 401(k)

• Potential eligibility for bonuses, commissions, or equity