Pharmacist (R)

Job Summary: Prior Authorization Pharmacist (Remote, EST)

This clinically focused Prior Authorization Pharmacist role sits within a leading managed care organization s pharmacy benefit management (PBM) team, supporting Medicaid, Medicare, and marketplace populations. The position empowers pharmacists to independently review, determine, and defend pharmaceutical coverage decisions using clinical judgment and established criteria, with direct impact on patient access and organizational compliance. The role is remote, follows standard business hours with occasional weekend rotation, and offers a clear exit path from retail dispensing into a payer-side, non-dispensing, clinician-driven environment.

Key Responsibilities

- Review prior authorization requests, applying medical necessity criteria and benefit guidelines
- Independently issue and document coverage determinations, escalating complex cases as needed
- Engage prescribers and provider offices for clinical information to support determinations
- Provide clinical expertise to customer care teams on medication and coverage questions
- Support fraud, waste, and abuse program oversight
- Meet or exceed department quality, accuracy, and turnaround standards
- Remain current on regulatory and operational changes, policies, and industry best practices

Recruiter Insights

- Attractive for pharmacists seeking a clinical, non-dispensing remote role with autonomy in decision-making
- Clinician-led environment decisions made by licensed pharmacists, not administrators
- Competitive market positioning for compensation, with mid-to-upper band responsibilities
- Opportunity for retail pharmacists to transition into managed care or payer roles
- Clear operational timeline due to PBM transition short-term contract with defined end date
- Preferred qualifications (not mandatory): PBM or managed care background, Medicaid/Medicare experience, support of fraud, waste and abuse programs, multi-state licensure, appeals/grievance review

Candidate Insights

- No dispensing volume, no bench work, no overnight shifts ideal for those seeking to leave retail environments
- Leverage clinical expertise to directly impact patient medication access and outcomes
- Structured, mission-driven organization with strong clinician presence and support
- Opportunity to develop payer-side experience in a highly reputable, accredited PBM
- Advance skills in utilization management and coverage determination in a supportive, collaborative setting
- Transparent contract duration ideal for candidates seeking interim or transition roles

Skills Emphasized

- Prior authorization review
- Coverage determination
- Clinical judgment
- Formulary and utilization management
- Independent case review
- Prescriber engagement and communication

This role is best suited for licensed pharmacists ready to exercise clinical authority in a remote, non-dispensing managed care setting, who thrive on meaningful decision-making and are comfortable with a defined contract period.