Pharmacist

Job Title: Clinical Pharmacist (Remote)
Location: Remote
Schedule: Monday-Friday, 8:00 AM - 5:00 PM or 9:00 AM - 6:00 PM
Additional Requirements: Rotational weekend coverage and occasional holiday coverage
Pay Rate: $65.00/hour

Position Overview
We are seeking an experienced Clinical Pharmacist to support our pharmacy coverage determination and appeals team during peak business periods. This role is responsible for reviewing complex clinical cases, conducting outreach, evaluating medical and pharmacy documentation, and making evidence-based recommendations to Medical Directors regarding pharmacy coverage decisions. The ideal candidate will have experience within a Pharmacy Benefit Management (PBM) environment, Medicare Part D knowledge, and a strong ability to navigate technology and clinical resources efficiently in a fast-paced remote setting.

Key Responsibilities

• Evaluate prescriptions, patient histories, and clinical documentation to support pharmacy coverage determinations and appeals.
• Interpret physician prescriptions and assess supporting clinical information using established criteria, compendia, and coverage guidelines.
• Review formulary policies and utilization management requirements to determine medication coverage eligibility.
• Research, evaluate, and render decisions on member and provider appeals related to pharmacy benefit coverage.
• Gather and analyze complex clinical information, including medical literature, coverage policies, and regulatory requirements.
• Consult with physicians, members, and internal stakeholders regarding medication use, drug interactions, and clinical status related to appeals requests.
• Collaborate with Medical Directors and treating physicians, when necessary, to support clinical decision-making.
• Conduct quality assurance reviews to ensure accuracy and compliance with regulatory and organizational standards.
• Provide clinical expertise and guidance to support staff regarding prescription medications and pharmacy-related inquiries.
• Maintain accurate documentation and detailed records of clinical reviews, determinations, and communications.

Required Qualifications

• Active, unrestricted Pharmacist license.
• Strong written and verbal communication skills.
• Experience using online clinical references, drug information resources, and regulatory websites.
• Ability to review and work with electronic clinical documentation and scanned documents.
• Intermediate proficiency with Microsoft Office Suite.
• Ability to navigate multiple systems within a Windows-based environment.
• Strong documentation, analytical, and organizational skills.

Preferred Qualifications

• Prior Pharmacy Benefit Management (PBM) experience.
• Doctor of Pharmacy (PharmD) degree.
• Pharmacy Residency training.
• Experience with Medicare Part D, Medicaid, and Commercial pharmacy benefit plans.
• Experience with Coverage Determinations, Prior Authorizations, and Appeals processes.
• Knowledge of pharmacy reimbursement, formulary management, and third-party insurance programs.
• Comfortable learning and utilizing multiple technology platforms and clinical systems.