The Clinical Pharmacist is responsible for conducting clinical reviews of prior authorization requests, ensuring that all determinations are evidence-based, compliant with regulatory standards, and aligned with clinical criteria. This role supports timely patient access to appropriate therapies while maintaining high standards of documentation, communication, and quality assurance.
Role and Responsibilities- Review and process medication prior authorization (PA) requests using clinical guidelines, compendia, and clinical criteria.
- Evaluate submitted documentation (diagnosis, labs, previous therapies) for completeness and appropriateness.
- Apply evidence-based clinical decision-making to approve or deny PA requests, documenting rationale clearly and concisely.
- Communicate with providers, prescribers, etc. regarding PA outcomes, additional information needs, or clarifications.
- Escalate complex or medical exception cases according to established protocols.
- Utilize internal platforms (e.g., PA Hub), formulary and criteria tools, and drug information resources (e.g., UpToDate/Lexicomp).
- Ensure compliance with HIPAA, PHI handling, and all regulatory requirements.
- Participate in quality assurance activities
- Support appeals, peer-to-peer reviews, and contribute to process improvement initiatives.
- Maintain up-to-date knowledge of formulary changes, clinical guidelines, and regulatory updates.
- Participate in meetings, team training and professional development of prior authorization processing, appeals, and any related clinical services issues.
- Assist with clinical program operations and special projects as required according to business needs.
Qualifications and Education Requirements- Requires a Doctor of Pharmacy or a BS, Pharmacy with equivalent experience
- Active pharmacist license, in good standing, in any US state
- Minimum of 2 years of experience in a PBM or health plan
Current clinical prior authorization review experience for managed care organizations.
Knowledge and Skills Required- Proficiency with Microsoft Office suite
- Excellent organizational, written and verbal communication
- Highly motivated and good interpersonal skills, self-starter
- Excellent critical thinking skills, detail-oriented
- Ability to adapt and perform duties efficiently whenever unexpected changes arise
- Works well in a fast-paced environment
- Knowledge of HIPAA regulations
PHYSICAL REQUIREMENTSThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
This is a largely sedentary role; however, some standing, walking, bending, and reaching may be required. Regularly operates in an office or home office setting which involves utilizing a computer, mouse, keyboard, and occasionally operating other standard office equipment, such as printer, copier, phone. Travel may be required by either car or airplane, or a combination of multiple modes of transportation.
Salary $84,800- $99,376
