Prior Authorizations Pharmacist – Full-Time

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

📋 Description

• Assess and analyze pharmacy prior authorization requests in line with benefit plans, clinical guidelines, client policies, and regulations.

• Complete reviews of prior authorization requests within set turnaround times.

• Utilize evidence-based criteria to evaluate the medical necessity and suitability of drug therapies.

• Identify opportunities for therapeutic optimization and cost-effective medication management.

• Suggest formulary alternatives to prescribing providers.

• Oversee clinical reviews of pharmacy benefit appeals.

• Convey coverage decisions and clinical rationale to providers, members, pharmacy staff, and stakeholders.

• Conduct calls with providers and members for the purpose of obtaining clinical information and providing consultation.

• Aid in the development, implementation, and upkeep of prior authorization criteria, clinical guidelines, and utilization management programs.

• Assist with formulary management initiatives such as step therapy, quantity management, and drug utilization programs.

• Examine clinical literature, pharmacy utilization data, prescribing trends, and utilization patterns.

• Create and analyze prior authorization reports, presenting findings and recommendations.

• Monitor KPIs and enhance clinical and operational performance.

• Streamline prior authorization workflows and drug utilization management processes.

• Offer clinical leadership, mentorship, onboarding, education, and training to clinical staff.

• Engage in quality assurance, audits, accreditation efforts, and process improvement projects.

• Ensure precise documentation and carry out assigned special projects.

• Maintain compliance with HIPAA, NCQA, URAC, client requirements, and federal and state regulations.

⛳️ Requirements

• Bachelor of Science in Pharmacy (BSPharm) or Doctor of Pharmacy (Pharm.D.) degree from an accredited college of pharmacy.

• Active, current, and unrestricted Pharmacist license.

• Licensure in additional states may be necessary based on business demands.

• At least one (1) year of direct experience in prior authorization or utilization management.

• Experience in applying evidence-based clinical guidelines within pharmacy practice.

• Strong clinical understanding of pharmacotherapy and evidence-based medicine.

• Familiarity with pharmacy benefit management operations and utilization management principles.

• Working knowledge of the Medi-Span drug database, including GPI drug classification.

• Proficient in Microsoft Excel, Microsoft Word, and pharmacy management systems.

• Excellent clinical judgment and critical thinking abilities.

• Strong written and verbal communication skills.

• Strong interpersonal and customer service capabilities.

• Strong organizational skills with the ability to prioritize multiple responsibilities while meeting deadlines.

• Capacity to work both independently and collaboratively within a multidisciplinary team.

🏝️ Benefits

• 401(k) with matching.

• Dental insurance.

• Health insurance.

• Vision insurance.

• Health savings account.

• Paid time off.

• Dynamic environment with clear opportunities for career advancement.

• Inclusive atmosphere and culture.

• Culture focused on empathy, mutual respect, and support for teams and clients.