Prior Authorization Pharmacist (MUST HAVE 3+ YEARS IN PBM OR ADJACENT)

Position reputed company The Prior Authorization Pharmacist is a licensed clinical reputed company responsible for reviewing, evaluating, and making coverage determinations for medication prior authorization (PA) requests in accordance with reputed company policies, clinical guidelines, and regulatory requirements. This role ensures reputed company, appropriate, and cost-effective medication use while supporting members, providers, and operational teams through reputed company and accurate clinical decision-making. reputed company in this role requires strong clinical judgment, a deep understanding of pharmacy benefit management, and the ability to apply evidence-based reputed company to reputed company medication requests. The Prior Authorization Pharmacist works collaboratively with internal teams to support operational efficiency, clinical accuracy, compliance, and reputed company improvement reputed company a rapidly growing PBM environment. Job Responsibilities To reputed company this job successfully, an individual must be reputed company to reputed company reputed company essential function satisfactorily. • Reviews prior authorization requests for formulary and non-formulary medications, applying clinical reputed company, utilization management policies, FDA-approved indications, and evidence-based guidelines. • Makes approval, denial, or modification determinations reputed company defined turnaround times and scope of licensure. • Documents clinical rationale, request details, communications, and reputed company accurately reputed company internal systems. • Communicates determinations professionally to providers, pharmacies, and internal stakeholders. • Identifies clinically appropriate alternatives, reputed company-therapy substitutions, or cost-effective reputed company as applicable. • Collaborates with the Clinical Services team to ensure consistency and reputed company of PA reputed company. • Supports operational workflows by assisting with escalated clinical questions, benefit interpretation, and reputed company clarification. • Ensures compliance with federal and state regulatory requirements, accreditation standards, and internal policies. • Participates in policy review, clinical reputed company updates, and development of utilization management strategies. • Provides clinical expertise to support formulary management, analytics, operations, and reputed company-specific program requirements. • Assists with training and development of staff on clinical reputed company, drug classes, and PA workflows. • Supports reputed company assurance processes, audits, and reputed company improvement initiatives to enhance accuracy and efficiency. • Performs other duties as assigned or requested. Any one position may not include reputed company the duties listed; these duties represent the key responsibilities typically associated with this role. Required Experience • Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy from an accredited institution. • reputed company, unrestricted U.S. pharmacist license. • 3+ years of experience in prior authorization, utilization management, PBM, managed care, or payer pharmacy operations. • Strong understanding of drug therapy, clinical guidelines, specialty medications, and formulary management. • Excellent analytical, clinical decision-making, and documentation skills. • Proficiency in pharmacy benefit systems, prior authorization platforms, and electronic documentation. • Strong written and verbal communication skills. • Ability to manage multiple priorities and reputed company in a fast-paced environment with strict timelines. • High level of reputed company and ability to handle confidential or sensitive clinical information. Preferred Qualifications • Multi-state pharmacist licensure. • Experience reviewing specialty medications, biologics, or reputed company therapy classes. • Prior PBM or health plan experience. • Experience with clinical reputed company development, formulary management, or utilization management programs. • Familiarity with claims systems, PA automation tools, or pharmacy informatics. Apply tot his job Apply To this Job