Pharmacy Prior Authorization Specialist for AI Evaluation

This role evaluates and validates AI tools that automate pharmacy benefit management and specialty medication prior authorization workflows, ensuring accurate, payer-compliant decisions that improve patient access to high-cost and specialty therapies. Key Responsibilities

• Process and manage prior authorization requests for specialty medications, biologics, and other high-cost pharmaceuticals across commercial, Medicare Part D, and Medicaid payers.
• Review clinical documentation and pharmacy benefit criteria to determine medical necessity for specialty drug authorizations.
• Evaluate AI-generated prior authorization recommendations for accuracy, completeness, and adherence to payer rules.
• Coordinate with prescribers, specialty pharmacies, and payers to obtain timely medication authorizations.
• Manage appeals for denied authorizations, including peer-to-peer requests and exception processes.
• Navigate payer formularies, step therapy requirements, and specialty drug coverage policies.
• Track authorization status, approval rates, and denial trends to identify opportunities for process improvement.
• Ensure compliance with payer-specific pharmacy benefit requirements and CMS Part D guidelines.
• Annotate AI outputs and provide structured feedback to support training datasets and improve system performance.

• Minimum 5 years of experience in pharmacy prior authorization, specialty medication access, or pharmacy benefit management.
• Deep familiarity with specialty drug formularies, step therapy protocols, and payer prior authorization criteria for commercial and government payers.
• Experience using specialty pharmacy platforms and pharmacy benefit management systems.
• Familiarity with Medicare Part D coverage determination and exception processes.
• Exceptional written and verbal English communication skills.
• High attention to detail, with the ability to evaluate clinical documentation and assess AI-generated outputs for accuracy.

• Certified Pharmacy Technician CPhT or Certified Prior Authorization Professional CPAP credential.
• Experience with hub services, patient assistance programs, manufacturer copay assistance, or specialty pharmacy access programs.
• Background in specialty pharmacy, infusion services, or therapeutic areas such as oncology or rheumatology.
• Comfortable evaluating AI-generated pharmacy content and providing feedback for model improvement.

• Location, remote.
• Employment type, hourly.

• Hourly rate, $75 per hour.

• Strong command of written and spoken English as required for reviewing clinical documentation and producing structured annotations.