Pharmacist - Prior Authorization Specialist
1 week ago
We are seeking a highly skilled Pharmacist to join our team as a Prior Authorization Pharmacist. In this role, you will be responsible for performing day-to-day clinical pharmacy functions, including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
Key Responsibilities- Perform day-to-day clinical pharmacy functions, including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls.
- Make clinical decisions in accordance with medical necessity and contract criteria.
- Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers.
- Communicate effectively with providers and members to promote positive health outcomes.
- Provide backup support to call center team as required.
- Review pharmacy claims data for proactive outreach and intervention.
- Support staff training and development as required.
- Identify and monitor inappropriate trends in care to improve quality and cost effectiveness.
- Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
- Support quality improvement programs/projects as required.
- Provide support for clinical programs, including creation and maintenance of prior authorization criteria guidelines and decision trees.
- Work with business and clinical partners as needed.
- Active, unrestricted, pharmacist license required.
- Bachelors or Doctorate of Pharmacy Degree required.
- 2+ years of pharmacy practice experience required.
- Managed care or PBM pharmacy experience required.
- Medicare Part D experience preferred.
- Proficient in Microsoft office Suite with emphasis on Microsoft Excel.
- Available to work during peak season from January-March (no planned extended vacations will be approved).
- Available to work a shift from either 11am-8pm EST or 2pm-11pm EST that will be assigned to you, along with rotating weekends.
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Clinical Pharmacist
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