Pharmacist

Job Description

Duties and Responsibilities:

• Review and evaluate prior authorization requests for pharmaceutical products.
• Make coverage determinations based on medical necessity, benefit design, prior authorization criteria, clinical guidelines, and regulatory requirements.
• Exercise independent clinical judgment while adhering to company policies and quality standards.
• Collaborate with Pharmacist II team members and leadership for complex cases and escalations.
• Communicate with healthcare providers to obtain additional clinical information and support coverage determinations.
• Provide clinical support to the Customer Care Center.
• Assist in oversight activities related to Fraud, Waste, and Abuse (FWA) programs.
• Stay current with pharmacy regulations, industry trends, clinical guidelines, and operational updates.
• Maintain productivity, quality, and service level expectations while ensuring compliance with organizational policies.

Qualifications:

• Bachelor’s Degree, PharmD preferred.
• Current Pharmacist license.
• Active Pharmacist license in good standing.
• Minimum 1 year of experience as a Pharmacist.
• Prior experience with Prior Authorization or Coverage Determination reviews.
• Experience working for a health insurance company, PBM, or managed care organization.