Prior Authorization Pharmacist

Pharmacist, Prior Authorization (Pa) & Appeals

The pharmacist, prior authorization (pa) & appeals, is responsible for reviewing and evaluating prior authorization and appeals requests to determine coverage based on clinical guidelines, pharmacy policies, and health plan benefits. In this fast-paced, high-volume environment, the pharmacist works closely with physicians, healthcare providers, pharmacy technicians, and internal teams to gather and assess clinical information, make evidence-based coverage determinations, recommend formulary-compliant and cost-effective treatment alternatives, and ensure compliance with federal and state regulations. The role requires strong clinical judgment, attention to detail, effective communication skills, and the ability to manage competing priorities while meeting productivity and quality standards. Additionally, the pharmacist supports quality assurance initiatives, resolves provider and pharmacy inquiries, participates in process improvement efforts, and contributes to a collaborative, customer-focused team environment. Maintain full compliance with state and federal pharmacy laws, medicare part d, medicaid, and commercial benefit regulations. Accurately document case decisions in accordance with internal protocols, auditing standards, and confidentiality policies. Effectively manage case volume by organizing workload, setting daily priorities, and meeting productivity and quality benchmarks. Adapt to fluctuating demands while maintaining accuracy and professionalism under pressure.

Skills and requirements:

• Bachelors or doctorate of pharmacy; active state pharmacist license
• current licensed pharmacist within the state of work
• 6+ months of customer service/customer relations with healthcare professionals
• technology savvy - basic proficiency with microsoft excel (ability to create, edit, and save a basic spreadsheet), microsoft word (ability to create, edit, and save a basic document) and basic proficiency with microsoft outlook (ability to send emails)
• comfortable with call center / production-based environment
• ability to perform responsibilities and duties remotely with little to no supervision
• comfortable in a fast-paced, high-volume workload
• ability to be adaptable, team-oriented culture requiring flexibility and adaptability to changing business needs.