Job Description

Job Description

Clinical Pharmacist - Prior Authorization

Job Summary

We are seeking a Clinical Pharmacist to work in our Prior Authorization unit, reviewing cases and rendering coverage determinations based on clinical criteria and plan design in a fast-paced environment. This role requires collaboration with medical directors to render final decisions on coverage determinations and excellent communication skills to work effectively with healthcare professionals and internal teams.

Primary Responsibilities

• Clinical Support and Decision-Making : Serve as a clinical resource, reviewing prior authorizations, gathering clinical information, and interpreting medical and pharmacy policy criteria to make coverage determinations.
• Coverage Determination and Consultation : Consult with prescribing physicians and healthcare providers to clarify clinical questions, interpret guideline criteria, and provide decisions on prior authorization requests.
• Medication Utilization Review : Collaborate with pharmacy technicians and prescribers to provide clinical insights on medication usage, recommending cost-effective alternatives when applicable.
• Regulatory and Policy Compliance : Maintain compliance with state and federal pharmacy laws, Medicare Part D, Medicaid, and commercial benefit regulations.
• Case Review and Clinical Assessment : Apply critical thinking to gather and evaluate complex medical and pharmacy data, making consistent and accurate coverage determinations.
• Workload and Time Management : Effectively manage case volume, prioritize tasks, and meet productivity and quality benchmarks.
• Team Collaboration and Communication : Demonstrate excellent interpersonal and communication skills, fostering a cooperative work environment.
• Customer Service and Conflict Resolution : Respond promptly to inquiries and concerns, resolving escalated issues with a service-first mindset.
• Quality Assurance and Continuous Improvement : Participate in audits, process evaluations, and training initiatives to support quality and service enhancements.

Requirements

• Education and Licensure : Bachelor's or Doctorate of Pharmacy; Active State Pharmacist License
• Customer Service Experience : 6+ months of customer service experience with healthcare professionals
• Technical Skills : Basic proficiency with Microsoft Excel, Word, and Outlook
• Availability : Able to work flexible hours, including overtime and weekends, with a schedule ranging from 5am to midnight
• Home Office Requirements : Own home internet access, secure workspace, and level skill with working with PC

Additional Information

• Training : 5-week training program with 8-hour shifts, Monday-Friday
• Shift Schedule : 8-hour shifts with 1-hour lunch, 5 days a week, potentially including weekend days
• Overtime and Holidays : May be required to work scheduled overtime and holidays dependent on business needs

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