Pharmacist, Prior Authorization and Appeals - Remote
Overview
You will own the clinical review of prior authorization and appeals requests for a high-volume, fully remote pharmacy team. You will apply evidence-based guidelines to make coverage decisions across Medicare Part D, Medicaid, and commercial plans. Working with physicians, pharmacy technicians, and internal teams, you will resolve inquiries, support quality initiatives, and improve processes. This role offers direct impact on patient access to medications in a collaborative environment.
What You'll Do8
- 1Review prior authorization and appeals requests to determine coverage based on clinical guidelines and pharmacy policies.
- 2Make evidence-based coverage determinations for formulary compliance and cost-effective alternatives.
- 3Communicate with physicians and providers to gather clinical information and resolve inquiries.
- 4Document case decisions in accordance with internal protocols and confidentiality policies.
- 5Manage case volume by organizing workload and setting daily priorities to meet quality benchmarks.
- 6Collaborate with pharmacy technicians and internal teams to ensure accurate and timely processing.
- 7Support quality assurance initiatives by participating in audits and process improvements.
- 8Maintain compliance with state and federal pharmacy laws, including Medicare Part D and Medicaid regulations.
Requirements8
- 1Current Pharmacist license in good standing.
- 21+ years of experience in prior authorization, appeals, or managed care pharmacy.
- 3Strong knowledge of Medicare Part D and Medicaid regulations.
- 4Experience with pharmacy benefit managers and claims processing systems.
- 5Ability to interpret clinical guidelines and apply them to coverage decisions.
- 6Proficiency with pharmacy software and electronic health records (EHR).
- 7Excellent written and verbal communication skills.
- 8Ability to work independently in a remote environment.
Salary Insight
$123k per year
Location
Required Skills
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