Prior Authorization Systems Pharmacist

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

📋 Description

• Accountable for the design, configuration, and quality assurance of prior authorization (PA) criteria.

• Develop decision trees and question sets based on PA criteria for the prior authorization review process.

• Execute thorough quality control (QC) assessments of decision trees, questionnaires, and authorization logic.

• Perform QA validation of the established criteria and decision pathways.

• Oversee the setup, contracting, and relationships with external vendors involved in prior authorization.

• Ensure that PA questionnaires are configured with the correct authorization parameters necessary for approval.

• Collaborate with external clients regarding delegated clinical PA systems services.

• Identify reporting requirements for PA and work with relevant stakeholders to create reports.

• Confirm that denial rationales, approval language, and conditional messaging accurately represent clinical criteria.

• Create and maintain policies and procedures for the development and upkeep of clinical criteria questions and letter templates.

⛳️ Requirements

• Valid, unrestricted pharmacist license is mandatory.

• A minimum of 3 years of experience in health plan or PBM pharmacy is required.

• Strong clinical background coupled with effective presentation skills is essential.

• Proficiency in Microsoft Excel and Word; must be capable of working with structured data and conducting basic analysis.

• Experience in supporting system testing (UAT, regression, or configuration validation) is necessary.

• Exceptional attention to detail with an emphasis on data accuracy and configuration quality.

• Ability to troubleshoot system or workflow issues and communicate effectively with both technical and non-technical stakeholders.

🏝️ Benefits

• Medical and pharmacy coverage.

• Dental insurance.

• Vision insurance.

• Accidental injury insurance.

• Critical illness insurance.

• Hospital indemnity insurance.

• Flexible spending accounts.

• Health savings account for full-time employees.

• Voluntary life insurance.

• Voluntary accidental death and dismemberment insurance for employees and eligible dependents.

• Basic life insurance at no cost.

• Basic accidental death and dismemberment insurance at no cost.

• Paid time off.

• Sick time.

• Holidays.

• Short-term disability.

• Long-term disability.

• Employee assistance program.

• Wellness program.

• 401(k) plan with company match after one year of full-time employment.