Remote Clinical Pharmacist – Prior Authorization Reviewer (Medicare Pharmacy)
Location: Detroit, MI, Remote (may require 1 day a week in office)
Job Type: W2
Schedule: Monday- Friday, 9:00 AM -5:30 PM
Pay Range: $70-71 per hour
Job Description:
We are seeking a Clinical Pharmacist to support Medicare pharmacy operations through the review and management of prior authorization requests. This role is responsible for evaluating medication coverage requests using CMS regulations, clinical coverage criteria, and established pharmacy benefit guidelines. The ideal candidate will have prior authorization experience in a PBM environment, strong clinical judgment, and the ability to manage a high-volume workload while collaborating with internal and external stakeholders.
Key Responsibilities
- Review and evaluate prior authorization requests for pharmacy benefit coverage.
- Apply CMS regulations, clinical coverage criteria, and pharmacy benefit guidelines to determine coverage eligibility.
- Assess clinical documentation and supporting medical information to make evidence-based coverage decisions.
- Communicate authorization determinations and coverage requirements to providers and other stakeholders.
- Collaborate with pharmacists, healthcare providers, and internal teams to resolve coverage and benefit-related questions.
- Manage multiple cases simultaneously while prioritizing urgent requests and meeting service-level expectations.
- Accurately document case activity, decisions, and communications within internal systems.
- Utilize Microsoft Office applications and proprietary systems to support workflow management.
- Participate in rotating weekend and holiday coverage schedules as needed.
- Foster a collaborative team environment and maintain effective working relationships with internal and external partners.
Required Qualifications
- Doctor of Pharmacy (PharmD) or equivalent.
- Prior authorization experience within a Pharmacy Benefit Management (PBM) environment.
- Experience utilizing clinical resources, CMS regulations, and clinical coverage criteria.
- Ability to effectively prioritize workload and adapt to changing business needs.
- Strong verbal and written communication skills.
- Advanced proficiency with Microsoft Office products and the ability to quickly learn new systems.
- Strong team-oriented mindset with a commitment to collaboration and customer service.
Benefits: 40-80 hours paid time off, medical insurance contributions, dental & vision and our 401k retirement savings plan
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