Job Description:
Job Title: Clinical Pharmacist 1
Assignment Duration: 3 Months (Possible Extensions)
Location: Remote
Working Hours: 9am 6pm EST Mon-Fri
Position Summary:
The Clinical Pharmacist is responsible for reviewing and analyzing prior authorization and pharmacy claims requests to determine medical necessity, appropriateness, and formulary compliance. This role supports quality, cost-effective healthcare delivery and ensures timely resolution of service authorization requests while collaborating with healthcare providers, pharmacy technicians, and internal teams.
Key Responsibilities:
Review and evaluate pharmacy prior authorization requests and recommended denials to determine appropriateness of therapy using clinical judgment and evidence-based guidelines.
Verify member eligibility, prescription benefit coverage, and health plan benefit information.
Evaluate prescription claim history, laboratory results, chart notes, and provider specialty as necessary.
Apply medical policy criteria, professional clinical judgment, and formulary guidelines to approve or deny requests.
Draft criteria and recommendations for non-formulary medication requests.
Communicate with providers regarding prior authorization status, plan benefits, quantity limits, age restrictions, formulary alternatives, and clinical guidance.
Research and provide clinical drug information to providers and pharmacy staff to support safe and effective medication management.
Compile data for reporting purposes, including non-formulary utilization, overturned denials, high-cost claims, and formulary recommendations.
Support pharmacy committee decisions and initiatives, including national P&T committees or formulary updates.
Maintain accurate documentation of all review activities and ensure compliance with regulatory, legal, and organizational standards.
Participate in process improvement initiatives and contribute to a collaborative, learning-oriented team environment.
Required Qualifications:
Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy.
Active pharmacist license in good standing with any U.S. state or ability to obtain licensure in the required state within 6 months.
0 2 years of professional pharmacy experience.
Proficiency with Microsoft Office applications and accurate data entry.
Strong sense of urgency, accountability, and attention to detail.
Preferred Qualifications:
Experience in managed care, health plan, or clinical pharmacy environments.
Knowledge of Medicare and Medicaid regulations.
Typing speed of 50+ WPM.
Experience with pre-service, concurrent, or post-service authorization review.
Performance Expectations:
Review an average of 85 100 cases daily with high accuracy.
Demonstrate professionalism, independent decision-making, and efficiency in a fast-paced environment.
Collaborate effectively with a supportive and cross-functional team.
Work Environment:
Remote work within the assigned time zone.
Fast-paced, dynamic workflow with opportunities to enhance clinical decision-making and problem-solving skills.
Key Attributes for Success:
Self-motivated with strong time management skills.
Goal-oriented and able to prioritize multiple tasks.
Strong communication and collaboration skills.
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