Clinical Review Pharmacist – 6-month, full-time contract

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

📋 Description

• Evaluate and render prompt, evidence-based decisions regarding prior authorizations and appeals utilizing clinical guidelines and benefit criteria.

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

• Accurately record clinical decisions and maintain comprehensive documentation in compliance with regulatory and accreditation standards (URAC/NCQA) for utilization review.

• Offer clear and compassionate assistance to members, prescribers, and pharmacies by addressing clinical inquiries.

• Keep abreast of clinical prescribing guidelines, internal policies, and changes in regulations.

• Adhere to internal procedures, job aids, and HIPAA regulations to safeguard patient privacy and data security.

• Identify and report any potential instances of fraud, waste, and abuse (FWA).

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

• Aid 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.

• Capability to handle multiple priorities in a fast-paced, metrics-driven setting.

• General knowledge of drug information, clinical guidelines, formulary design, and utilization management strategies.

• Ability to be flexible and adaptable to evolving circumstances.

• Willingness to work after hours, on 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: Direct experience in 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.