Apply evidence-based clinical guidelines to authorization decisions
Authorize, modify, or deny medication requests and document rationale
Collaborate with clinical staff to resolve complex cases
Job description
Our Client, a Retail Pharmacy company, is looking for a Clinical Pharmacist - Prior Authorization for their Remote location.
Responsibilities:
Review, assess, adjudicate medication prior authorization requests for medical necessity, clinical appropriateness, and formulary compliance.
Apply evidence-based clinical guidelines, drug compendia, FDA labeling, and plan-specific criteria to authorization decisions.
Evaluate patient-specific factors including diagnosis, laboratory results, prior therapy, dosing, contraindications, and comorbid conditions.
Authorize, modify, or deny medication requests and document clinical rationale clearly and accurately.
Collaborate with pharmacy technicians, nurses, medical directors, and other clinical staff to resolve complex cases.
Support peer-to-peer reviews and prepare clinical summaries when escalation is required.
Ensure compliance with state and federal regulations, accreditation standards (e.g. NCQA, URAC), and internal audit requirements.
Maintain productivity, turnaround time, and quality benchmarks for prior authorization processing.
Document all activities accurately within prior authorization and pharmacy management systems.
The Prior Authorization Pharmacist is responsible for reviewing and evaluating medication prior authorization requests to ensure appropriate, safe, and cost-effective therapy in accordance with clinical guidelines, regulatory requirements, and organizational policies.
This role applies clinical judgement to support optimal patient outcomes while balancing utilization management objectives.
Requirements:
Active and unrestricted AZ or TX pharmacist license.
Experience with clinical decision-making while applying evidence based clinical guidelines/criteria; utilizing formularies/preferred drug lists.
Experience working in a high production team environment.
3+ years’ experience working as a pharmacist.
Knowledge of clinical program components, formulary designs, and prescription benefit trends.
Bachelor's degree in pharmacy or Pharm D. required with at least two years experience as a pharmacist. Must have an active license in good standing.
