Remote / Work from Home Pharmacist - Prior Authorization

Job Title: Clinical Pharmacist
The Clinical Pharmacist evaluates prior authorization and appeal requests by reviewing clinical documentation and making coverage determinations based on established criteria. This role focuses on clinical evaluation rather than dispensing, and involves close collaboration with prescribers, pharmacies, and internal teams to gather necessary information, document decisions, and communicate outcomes. The pharmacist ensures all reviews are accurate, timely, and compliant with applicable regulatory and client requirements, while actively contributing to process and workflow improvements within the prior authorization program and making a meaningful impact on patient care.
Review prior authorization and appeal requests by evaluating clinical documentation and applying established clinical and coverage criteria.
Make clear, defensible coverage determinations and document medical necessity decisions in a thorough, accurate, and compliant manner.
Collaborate with prescribers, pharmacies, and internal teams to obtain complete and accurate clinical information needed for coverage decisions.
Communicate coverage decisions and clinical rationale to providers, pharmacies, or members in both written and verbal form.
Differentiate between medical benefit and pharmacy benefit coverage and apply appropriate criteria and workflows for each.
Support appeals processing by preparing or reviewing first-level, second-level, or external review submissions as needed.
Use pharmacy benefit management platforms, prior authorization systems, workflow tools, ticketing systems, or case management systems to manage clinical reviews and track case progress.
Work efficiently in a production-driven, high-volume environment while maintaining strong attention to detail, accuracy, and quality standards.
Ensure all prior authorization and appeal reviews comply with CMS, state-level, and payer regulatory requirements.
Identify workflow or policy inefficiencies and contribute to process improvements within the prior authorization program.
Participate in a culture of continuous improvement by providing and receiving constructive feedback to enhance quality and efficiency.
Leverage technology and digital platforms, including Microsoft Office and shared documentation tools, to support daily clinical review activities.
Active pharmacist license in the state of residence.
Doctor of Pharmacy (PharmD) degree or equivalent pharmacy education.
Prior experience with prior authorization review (strongly preferred).
Experience working with multiple pharmacy benefit management (PBM) platforms and payer-specific prior authorization workflows.
Familiarity with medical benefit versus pharmacy benefit coverage determinations.
Exposure to appeals processing, including first-level, second-level, or external review submissions.
Working knowledge of managed care, utilization management, or health plan operations.
Experience communicating clinical rationale to providers, pharmacies, or members in written and verbal formats.
Understanding of CMS, state-level, and payer regulatory requirements related to prior authorization.
Ability to work efficiently in a production-driven, high-volume environment while maintaining quality and accuracy.
Strong attention to detail with a commitment to accuracy and quality in clinical decision-making and documentation.
Proficiency with technology and digital platforms, including Microsoft Office, shared documentation tools, PBM systems, and the ability to quickly learn new systems.
Pharmacy benefits management (PBM) experience.
Experience in managed care or health plan settings.
Experience supporting high-volume or metrics-driven environments while maintaining high quality standards.
Ability to identify process inefficiencies and contribute to workflow or policy improvements.
This role is a 100% work-from-home position, allowing the Clinical Pharmacist to perform all responsibilities remotely. The majority of the workday is spent seated at a desk using a computer for clinical review activities. The position requires regular use of a computer keyboard, mouse, and calculator, as well as frequent interaction with digital platforms such as PBM systems, workflow tools, and shared documentation applications. On occasion, the role may require lifting up to 15 pounds, such as moving equipment or materials in the home office environment. The work setting is production-driven and metrics-oriented, yet emphasizes quality, accuracy, and thoughtful clinical decision-making over volume alone, offering a professional, technology-enabled environment where pharmacists can focus on clinical evaluation and coverage decisions.
This is a Contract position based out of Birmingham, AL.
If eligible, the benefits available for this temporary role may include the following:

• Medical, dental & vision
• 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Employee Assistance Program
• This is a fully remote position.

Application Deadline
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