Job Description

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.

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