Senior Clinical Review Operations Pharmacist

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

📋 Description

• Identify gaps in operational processes and advocate for technology-based solutions to enhance throughput, scalability, and workflow efficiency.

• Offer clinical guidance, coaching, and onboarding assistance to fellow pharmacists.

• Serve as a senior operational contact for intricate clinical cases, escalated coverage determinations, and appeals.

• Collaborate with internal teams to resolve eligibility inquiries, claims adjudication issues, and nuances in benefit design.

• Work with clinical leadership and the Pharmacy and Therapeutics Committee to create, refine, and assess clinical criteria for medications that require prior authorization.

• Achieve or surpass individual target KPIs and turnaround-time SLAs.

• Promote the adoption of new technologies, workflow tools, and updated clinical protocols throughout the Clinical Review team.

⛳️ Requirements

• Over 5 years of experience in health plans or Pharmacy Benefit Managers (PBM), particularly in prior authorization review and clinical operations.

• Proven expertise as a clinical subject matter expert with a history of implementing process improvements or technology-driven efficiencies.

• An active, unrestricted Pharmacist License is required.

• A Bachelor’s degree in Pharmacy or a Doctor of Pharmacy (PharmD) is necessary.

• Strong skills in using Mac, MS Office, and G-Suite platforms.

• Exceptional active listening and communication abilities to articulate complex clinical information.

• Excellent multitasking, time management, and problem-solving skills.

• In-depth knowledge of drug product/dose calculations, claim adjudication regulations, and general pharmacy dispensing procedures.

• Ability to adapt to changing clinical guidelines, protocols, and new operational technologies.

🏝️ Benefits

• Medical, Pharmacy, Dental, Vision, and Life Insurance

• AD&D Insurance

• Flexible Spending Benefits

• 401(k) Retirement Savings Program

• Short-term and long-term disability

• Discretionary Paid Time Off

• Paid Company Holidays

• Wellness Benefits

• Commuter Benefits

• Paid Parental Leave benefits

• Employee Assistance Program (EAP)

• Well-stocked kitchen in office locations

• Professional development and training opportunities

• Time off programs

• Mental health support

• Bonuses, commissions, or equity may be available