We are seeking a licensed Pharmacist with experience in Prior Authorization, PBM, and Medicare Part D . The ideal candidate will have strong clinical review skills and experience evaluating medication requests, applying coverage and formulary requirements, and collaborating with providers to support appropriate medication access.
Responsibilities
- Review Prior Authorization (PA) requests for clinical appropriateness and coverage requirements.
- Evaluate patient medical records, medication history, and clinical documentation to support PA determinations.
- Apply PBM, Medicare Part D, formulary, and plan-specific criteria when reviewing medication requests.
- Review medications for dosing, safety, drug interactions, contraindications, and therapeutic appropriateness.
- Conduct clinical reviews for prescription and specialty medications.
- Communicate with physicians, pharmacists, and healthcare providers to obtain additional clinical information when needed.
- Support coverage determinations and medication access decisions.
- Resolve pharmacy benefit, formulary, and insurance-related issues.
- Document clinical reviews, decisions, and provider communications accurately.
- Ensure reviews are completed within applicable Medicare Part D/PBM guidelines and required timelines .
- Collaborate with internal clinical and pharmacy teams to resolve complex medication-related cases.
Qualifications
- Active and unrestricted RPh/PharmD license .
- 2+ years of Prior Authorization / Clinical Review experience preferred.
- Experience with PBM, Managed Care, Health Plans, or Specialty Pharmacy .
- Strong experience with Medicare Part D .
- Knowledge of formulary requirements, coverage criteria, and pharmacy benefits.
- Strong clinical assessment and medication review skills.
- Excellent provider communication and documentation skills.
- Ability to work independently in a remote environment.
Remote Pharmacist in workfromhome at Unknown Company
This position is listed as full time and able to be worked remotely.