Clinical Review Pharmacist – Seasonal

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

📋 Description

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

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

• Meticulously document clinical decisions and uphold comprehensive records in line with URAC/NCQA utilization review standards.

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

• Remain updated on clinical prescribing guidelines, internal policies, and changes in regulations.

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

• Detect and report potential fraud, waste, and abuse (FWA).

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

• Support leadership in special projects, process enhancements, and operational initiatives.

⛳️ Requirements

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

• An active, unrestricted pharmacist license in your state of residence.

• A minimum of 2 years of experience in pharmacy practice.

• Excellent communication, writing, and organizational abilities.

• Capability to handle multiple priorities within a high-volume, metric-driven setting.

• Fundamental understanding of drug information, clinical guidelines, formulary design, and utilization management strategies.

• Adaptable and flexible in response to change.

• Willingness to work after hours, on weekends, and holidays according to a rotating or fixed schedule.

• Preferred: At least 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 with prior authorization reviews, clinical appeals, formulary exceptions, step therapy evaluations, and quantity limit reviews.

• Preferred: Proficiency in Google Workspace (Gmail, Docs, Sheets, and Drive).

🏝️ Benefits

• Bonuses, commissions, or equity may be available.

• Time off programs.

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Mental health support.

• Paid parental leave.

• Life insurance.

• Disability insurance.

• 401(k).