Pharmacist Prior Authorization Specialist

2 days ago


New York, New York, United States Capital Rx Full time
Job Summary

A Prior Authorization Pharmacist at Capital Rx performs day-to-day clinical pharmacy functions, including prior authorization and appeal reviews, override requests, and inbound and outbound member and provider education calls, while following medical necessity and contract criteria.

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 the 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.
Requirements
  • Active, unrestricted, pharmacist license required.
  • Bachelor's 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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