Clinical - Clinical Pharmacist 1 - 210392

Job Description:

Job Title: Clinical Pharmacist

Duration: 4 months (Possible Extension)

Location: Remote

Shift: Monday Friday, 9am 6pm EST.

Position Summary:

Seeking a dedicated and detail-oriented Clinical Pharmacist to join our growing Pharmacy Appeals team. In this role, you will utilize your clinical expertise to review redetermination and appeal coverage requests, evaluate prior authorizations, and ensure optimal pharmacological decision-making based on policy, member benefits, and evidence-based criteria.

This is an ideal opportunity for a licensed pharmacist with prior experience in managed care or clinical decision-making environments who thrives in a fast-paced, collaborative, and high-volume workflow.

Key Responsibilities:

• Evaluate and process pharmacy prior authorization appeals and redetermination requests in compliance with medical policy criteria.

• Review and verify member and provider information, prescription claim history, chart notes, and lab results.

• Apply clinical judgment to non-formulary and medically necessary drug requests, including interpretation of guidelines and benefit coverage.

• Communicate effectively with providers regarding benefit exclusions, formulary alternatives, quantity limits, and age restrictions.

• Draft and update medication criteria and support National Pharmacy & Therapeutics (P&T) Committee with relevant data.

• Participate in data gathering, analysis, and reporting related to formulary management, utilization trends, and overturned decisions.

• Maintain adherence to state and federal drug laws and professional pharmacy standards.

• Contribute to the department's team culture by participating in education, knowledge sharing, and ongoing improvement processes.

Candidate Requirements:

Education & Licensure:

• Doctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy (required)

• Active and unrestricted Pharmacist license in any U.S. state (required)

  • Must obtain licensure or registration (as applicable) in the following required states: AL, AR, ID (registration), KY, LA, MD, MI, MS, NE, OK, OR, TN, WV

  • Must be in good standing with the State Board of Pharmacy

Experience:

• Minimum of 1 year of experience as a licensed pharmacist (required)

• Experience with Medicare/Medicaid law, managed care, or pharmacy benefit management (PBM) (preferred)

Key Skills & Attributes:

• Strong time management and ability to work independently in a remote environment

• Working knowledge of Microsoft Office Suite (Word, Excel, Outlook)

• Strong decision-making, critical thinking, and organizational skills

• Goal-oriented with a high level of attention to detail

• Comfortable in a fast-paced, task-driven setting

• Excellent written and verbal communication skills

Performance Expectations:

• Ability to review and sign off on 85 100 cases daily

• High accuracy in applying clinical and policy criteria

• Timely documentation and responsiveness to internal and external queries