The Clinical Pharmacy Reviewer (Pharmacist) evaluates complex prior authorization requests, appeals, and medication coverage determinations to ensure clinical appropriateness and compliance with evidence-based guidelines. Acting as a subject matter expert in pharmacy benefit management, this role interprets complex drug criteria, formulary guidelines, step therapy, and quantity limits for specialty and non-specialty medications. Through rigorous Drug Utilization Review (DUR) and objective decision-making, the Clinical Pharmacy Reviewer upholds medical necessity standards, directly impacting Dane Street's commitment to high-quality healthcare delivery and regulatory excellence.
RequirementsEDUCATION/CREDENTIALS:
- Doctor of Pharmacy (PharmD) degree from an accredited university.
- Active, unencumbered pharmacist license in any U.S. State.
Must Haves:
- Minimum of 3 years of Prior Authorization and/or Appeals review experience within a PBM environment.
Preferred Qualifications:
- Experience with Medicare Part D and Medicaid pharmacy benefits.
- Knowledge of commercial insurance pharmacy benefits and formulary management strategies.
- Knowledge of step therapy requirements, quantity limit programs, and specialty medications.
- In-depth knowledge of Drug Utilization Review (DUR).
- Demonstrated ability to interpret and apply complex clinical guidelines.
BenefitsWhy Join Dane Street?
- Collaborative remote culture
- Professional growth opportunities
- Meaningful work supporting the healthcare industry
- Comprehensive benefits
- Great Place to Work Certified since 2021
- Commitment to employee development
WORK FROM HOME TECHNICAL REQUIREMENTS:
Supply and support their own internet services.
Maintaining an uninterrupted internet connection is a requirement of all work-from-home positions.
