Pharmacist I – Clinical Prior Authorization

This is a fully remote position, open to applicants in Alabama, +34 more locations.

📋 Description

• Conduct Prior Authorizations.

• Execute tasks associated with Drug Utilization Review, encompassing concurrent, retrospective, and prospective elements.

• Assist Customer Care with clinical inquiries necessitating pharmacist involvement.

• Collaborate with physicians, pharmacists, and specialty pharmacy providers regarding beneficiaries’ benefits and therapeutic interventions.

• Analyze and assess health surveys and utilization data for program management and development.

• Contribute to and support clinical programs such as Health Management, Drug Utilization Review, Formulary development, and Prior Authorization initiatives.

• Engage in the Coverage Determination process by evaluating requests that are not evidently approvable based on established criteria, making decisions on coverage denials, and identifying themselves concerning drug utilization management program administration.

• Oversee the quality and efficiency of the Coverage Determination process, including coverage criteria, denial language, and communication with prescribers.

• Provide input on the clinical content of new programs and maintain current programs.

• Fulfill all annual URAC training requirements.

• Facilitate communication and education for clients, members, and internal staff regarding daily clinical issues and objectives.

• Assist operational departments in implementing and managing PBM programs to support member/patient quality of care.

• Offer clinical expertise related to formulary decisions made by the Pharmacy and Therapeutics committee.

• Review health care survey data for Medicare Part D qualified participants and/or conduct phone consultations with Medicare Part D enrollees; assist in call documentation and designate enrollees for follow-up interactions.

• Perform additional duties as assigned.

⛳️ Requirements

• A minimum of a bachelor’s degree in Pharmacy or Pharm D.

• Current, unrestricted licensure as a Registered Pharmacist in the state of residence, or the capability to obtain reciprocity within 4 months, may be necessary based on state laws or client contracts.

• Additional State Pharmacy Licenses may be required as business needs arise.

• Must continuously maintain education credits to keep active licensure.

• Preferred two years of work experience in a clinical environment, or clinical or managed care pharmacy practice residency.

• Desired knowledge of the PBM industry, formulary management, pharmacy claims, and managed care principles and practices.

• Exceptional clinical skills and the ability to apply sound clinical judgment in various situations are essential.

• Preferred proficiency in drug literature and clinical trial evaluation, including experience with electronic databases (e.g., Micromedex, Medline, Internet).

• Ability to reason and convey clinical information in a manner suitable for clinical systems and both clinical and non-clinical audiences.

• Strong emphasis on problem-solving skills, including the ability to identify and accept challenging situations and develop and implement solutions.

• Requires meticulous attention to detail to ensure projects are clinically, editorially, and operationally accurate.

• Preferred proficiency in MS Word, Excel, PowerPoint, including tables, charts, and figures.

• Participate in, adhere to, and support compliance program objectives.

• Ability to consistently interact cooperatively and respectfully with colleagues.

🏝️ Benefits

• Competitive benefits package for Health, Dental, and Vision insurance.

• 20 days of paid time off.

• 4 weeks of paid parental leave.

• 9 paid holidays.

• 401K company match of up to 5% - No vesting requirement.

• Adoption Assistance Program.

• Flexible Spending Account.

• Educational Assistance Plan and Professional Membership assistance.

• Referral Bonus Program – up to $750!