Prior Authorization Pharmacist

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

📋 Description

• Conduct thorough clinical evaluations and oversee prior authorization requests for specialty pharmacy and infusion therapies.

• Evaluate clinical documentation in accordance with payer-specific medical necessity criteria, coverage policies, and clinical guidelines.

• Prepare, submit, and monitor prior authorization requests directed to PBMs and health plans.

• Liaise with PBMs and health plans to clarify clinical information, supply additional documentation, and resolve authorization challenges.

• Reduce denials by addressing rejections in real-time through direct outreach to PBMs and payers.

• Develop and submit evidence-based appeal letters including clinical rationale, literature support, and alignment with policies.

• Collaborate with the patient access team and internal stakeholders to gather documentation and enhance patient access to therapies.

• Track authorization outcomes and performance metrics to identify delays, obstacles, or trends.

• Remain updated on payer policies, clinical guidelines, and regulatory requirements.

• Identify opportunities for workflow and training enhancements and contribute to process improvement efforts.

⛳️ Requirements

• Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy from a recognized institution.

• Active, unrestricted U.S. pharmacist license.

• A minimum of 2 years of experience in prior authorization, utilization management, PBM, managed care, or payer pharmacy operations.

• Strong knowledge of drug therapy, clinical guidelines, specialty medications, and formulary management.

• Excellent analytical, clinical decision-making, and documentation abilities.

• Proficient in pharmacy benefit systems, prior authorization platforms, and electronic documentation.

• Strong written and verbal communication skills.

• Ability to manage multiple priorities and perform effectively in a fast-paced environment with strict deadlines.

• High integrity and capability to handle confidential or sensitive clinical information.

• Multi-state pharmacist licensure is preferred.

• Experience in reviewing specialty medications, biologics, or complex therapy classes is preferred.

• Prior experience with PBM or health plans is preferred.

• Background in clinical criteria development, formulary management, or utilization management programs is preferred.

• Familiarity with claims systems, PA automation tools, or pharmacy informatics is preferred.

• Competent in the use of Word, Excel, and PowerPoint.

• Must be able to communicate effectively with all levels within Soleo Health.

• Must actively support Soleo Health’s philosophy and objectives.

🏝️ Benefits

• Competitive Wages

• 401(k) with a Match

• Referral Bonus

• Paid Time Off

• Great Company Culture

• Annual Merit-Based Increases

• No Weekends or Holidays

• Paid Parental Leave Options

• Affordable Medical, Dental, & Vision Insurance Plans

• Company Paid Disability & Basic Life Insurance

• HSA & FSA (including dependent care) Options

• Education Assistance Program