Pharmacy Prior Authorization Specialist for AI Evaluation

Ensure timely patient access to specialty and high-cost medications by managing prior authorization workflows, interpreting payer coverage rules, and validating AI tools built to automate pharmacy benefit management and specialty drug authorization. This role combines deep clinical and payer knowledge with hands-on evaluation of AI-generated recommendations to improve accuracy and compliance across commercial, Medicare Part D, and Medicaid payers.

• 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 payer compliance.
• Coordinate with prescribers, specialty pharmacies, and payers to secure 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 process improvement opportunities.
• Ensure compliance with payer-specific pharmacy benefit requirements and CMS Part D guidelines.
• Annotate AI outputs and provide structured feedback to support AI training datasets.

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

• Certified Pharmacy Technician CPhT or Certified Prior Authorization Professional CPAP credential.
• Experience with hub services and patient assistance programs for specialty medications.
• Background in specialty pharmacy, infusion services, or oncology or rheumatology drug access.
• Comfort evaluating AI-generated pharmacy content and familiarity with AI tools.
• Experience with manufacturer copay assistance and patient access programs.

Location: Remote. Employment type: hourly. Candidates must be available to perform the responsibilities remotely and interact with clinical and payer stakeholders as required.

Hourly rate: $75 per hour.

Contribute clinical and payer expertise to shape next-generation AI systems in healthcare, work with a leading AI research organization, and gain exposure to innovative workflows in healthcare revenue cycle and specialty drug access.