Pharmacist Operations Advisor

Job Description

Job Summary:

• The Pharmacist/Clinician will conduct clinical reviews of prior authorization requests in accordance with policy, procedure, and clinical guidelines.
• This role requires applying clinical knowledge to coverage determinations, supporting the Prior Authorization team, and handling physician/member inquiries.
• Some on-call availability may be required for urgent requests.

Duties and Responsibilities:

1. Clinical Review (60%):

• Evaluate and review prior authorization requests.
• Verify insurance coverage and eligibility.
• Apply clinical guideline criteria to coverage determinations.
• Communicate decisions promptly to providers, patients, and health plans.

2. Knowledge Maintenance (10%):

• Stay current on drug and disease state knowledge for Specialty and Non-Specialty programs.

3. Other Duties (5%):

• Participate in training/development meetings.
• Provide after-hours/on-call support as needed.

Education, Experience and Certifications/ License:

• Bachelor’s degree (BS Pharmacy).
• Active pharmacist license in state of residence/practice.
• Experience in prior authorization, case review, or clinical review (commercial or specialty pharmacy preferred).
• Prior experience in a high-volume production setting meeting service-level agreements.

Skills:

• Strong multitasking skills with multiple technology platforms.
• Proficiency with Microsoft Office (Word, Excel).
• Excellent written and verbal communication skills.
• Doctor of Pharmacy (PharmD).