Clinical - Clinical Pharmacist 1 - 210392

Job Description

Position Title: Clinical Pharmacist 1

Location - Remote U.S.

Duration: 3 months Potential Extension

Schedule: Monday Friday, 9:00 AM 6:00 PM EST
Pay Range: XXXXXXXXXXX - XXXXXXXXXXX Per hr on w2.

Position Overview

We are seeking a Clinical Pharmacist 1 to support a Pharmacy Appeals team responsible for reviewing prior authorization requests, pharmacy appeals, coverage determinations, formulary requirements, and medication-related clinical criteria.

The Clinical Pharmacist will evaluate completed prior authorization requests, review clinical documentation and pharmacy claims history, apply medical policy criteria, determine whether requests meet approval criteria, and use professional clinical judgment to support appropriate medication access and utilization.

The ideal candidate will have at least 1 year of professional pharmacist experience, strong clinical judgment, excellent time-management skills, proficiency with Microsoft Office, and the ability to independently manage a high-volume workload.

Key Responsibilities

Prior Authorization & Clinical Review

• Review completed prior authorization requests and pharmacy technician-recommended denials for clinical appropriateness.
• Review suggested formulary alternatives, clinical comments, attachments, and supporting documentation.
• Verify member identification, date of birth, and eligibility within the appropriate health plan system.
• Verify prescription and health plan benefit coverage when required.
• Review previous prior authorization decisions.
• Evaluate prescription claim history, chart notes, and laboratory values.
• Apply Medical Policy Criteria to prior authorization requests.
• Determine whether medication requests meet established approval criteria.
• Perform case-by-case clinical review using independent professional pharmacist judgment.
• Review medication requests not addressed by P&T Committee criteria or established guidelines and develop/draft criteria for non-formulary medication requests.

Provider & Clinical Communication

• Research and provide drug references and clinical information to support prior authorization decisions.
• Communicate with physicians regarding:
  • Non-formulary medications
  • Plan benefits and exclusions
  • Quantity limits
  • Age restrictions
  • Formulary alternatives
• Communicate clinical information and educational guidance to pharmacy technicians as needed.

Pharmacy Appeals & Reporting

• Evaluate redetermination and appeal coverage requests.
• Retrieve and collect data using available reporting resources and systems.
• Compile data related to:
  • Non-formulary drug utilization
  • Overturned recommended denials
  • High-cost pharmacy claims
  • Formulary recommendations
  • Quantity/day supply limits
  • Age-limit requirements
  • National P&T Committee support
• Audit pharmacy claims greater than XXXXXXXXXXX00.
• Recommend additions or deletions of medications from the formulary when appropriate.
• Support updates to quantity, days-supply, and age-limit requirements.
• Perform additional pharmacy-related duties as required.

Compliance & Professional Practice

• Maintain compliance with applicable federal and state pharmacy laws and regulations.
• Maintain current pharmacist licensure and professional knowledge.
• Support safe, appropriate, and cost-effective medication utilization.
• Maintain accurate and confidential member and clinical information.
• Contribute to departmental goals and team objectives.

Required Qualifications

• Doctor of Pharmacy (PharmD) required.
• Current pharmacist license in good standing in any U.S. state.
• At least 1 year of professional Registered Pharmacist (RPh) experience required.
• Strong clinical judgment and decision-making skills.
• Excellent organization and time-management abilities.
• Self-motivated and goal-oriented.
• Ability to independently manage a high-volume workload.
• Working knowledge of Microsoft Office Suite.
• Strong written and verbal communication skills.

Preferred Qualifications

• Experience in managed care pharmacy.
• Knowledge of Medicare and Medicaid regulations/laws.
• Prior authorization experience.
• Pharmacy appeals or redetermination experience.
• Formulary management experience.
• Experience reviewing pharmacy claims.
• Experience applying medical policy or clinical criteria.

Performance Expectations

• Review and complete approximately 85 100 cases per day.
• Maintain accuracy while meeting productivity and turnaround expectations.
• Demonstrate strong time management and independent work capabilities.

• Meet departmental quality and performance standards.