Clinical Review Pharmacist

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

📋 Description

• Evaluate and make prompt, evidence-informed decisions regarding prior authorizations and appeals based on clinical guidelines and benefit criteria.

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

• Precisely document clinical decisions and maintain comprehensive records in accordance with URAC/NCQA utilization review standards.

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

• Keep abreast of clinical prescribing guidelines, internal policies, and regulatory updates.

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

• Identify and report potential instances of fraud, waste, and abuse.

• Assist in the training and development of 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.

• A minimum of 2 years of pharmacy practice experience.

• Excellent communication, writing, and organizational abilities.

• Capability to handle multiple priorities in a fast-paced, metric-driven environment.

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

• Flexible and adaptable to changes.

• Availability to work after hours, 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.