The pharmacist reviews prior authorization requests, appeals, and medication coverage determinations for clinical appropriateness and medical necessity. Work centers on interpreting drug criteria, formulary rules, step therapy, quantity limits, and other pharmacy benefit management standards for specialty and non-specialty medications. This is a remote, work-from-home role that relies on evidence-based decision-making and Drug Utilization Review in collaboration with a pharmacy benefit environment.
Key Responsibilities
- Conduct clinical reviews of prior authorization requests and appeals.
- Evaluate medication coverage determinations against evidence-based criteria.
- Interpret formulary guidelines, step therapy requirements, and quantity limit programs.
- Use Drug Utilization Review to support objective, medically necessary decisions.
- Assess specialty and non-specialty medication requests for clinical appropriateness.
- Coordinate with pharmacy benefit management workflows and review standards.
- Document determinations clearly and consistently within review processes.
Required
- Doctor of Pharmacy (PharmD) degree from an accredited university.
- Active, unencumbered pharmacist license in any U.S. state.
- At least 3 years of prior authorization and/or appeals review experience in a PBM environment.
Preferred
- Experience with Medicare Part D pharmacy benefits.
- Experience with Medicaid pharmacy benefits.
- Knowledge of commercial pharmacy benefits and formulary management.
- Knowledge of step therapy, quantity limit programs, and specialty medications.
- In-depth knowledge of Drug Utilization Review (DUR).
- Experience interpreting and applying complex clinical guidelines.
Benefits & Perks
- Remote work-from-home arrangement.
- Collaborative remote culture.
- Professional growth opportunities.
- Comprehensive benefits package.
- Commitment to employee development.
- Internet service required and supported as part of work-from-home setup.