Job Description
Job Title: Clinical Pharmacist I
Duration: 6 Months
Work Arrangement: Fully Remote
Work Schedule: 8-hour shift, typically 9:00 a.m. to 5:30 p.m. in the worker's local time zone
XXXX: XXXXXXXXXXX - XXXXXXXXXXX per hour
Extension/Conversion Potential: To be determined; temp-to-perm opportunity available
Position Overview
We are seeking a knowledgeable and detail-oriented Clinical Pharmacist I to join the Pharmacy Services team. This position primarily focuses on reviewing prior authorization requests for medical benefit medications, including buy-and-bill drugs, across Medicare, Medicaid, Exchange, and Commercial lines of business.
The Clinical Pharmacist will evaluate medication requests submitted by healthcare providers, apply established clinical criteria, and make timely, evidence-based determinations regarding medication coverage. The ideal candidate will possess strong clinical judgment, comprehensive drug knowledge, and experience with prior authorization reviews in a managed care organization or Pharmacy Benefit Management (PBM) environment.
This is a fully remote, six-month contract opportunity with the potential for conversion to a permanent position, depending on business needs and performance.
Key Responsibilities
- Review prior authorization requests for medical benefit medications, including buy-and-bill drugs, across Medicare, Medicaid, Exchange, and Commercial lines of business.
- Evaluate medication requests submitted by prescribing providers against established clinical criteria, medical necessity requirements, and applicable coverage policies.
- Make timely, accurate, and well-supported clinical decisions regarding medication approvals, denials, and requests requiring additional review.
- Apply clinical knowledge, pharmacotherapy principles, and evidence-based guidelines to assess the appropriateness, safety, and effectiveness of requested medications.
- Monitor prior authorization requests and ensure cases are processed within established turnaround-time requirements.
- Develop and recommend clinical criteria for medications, formulary strategies, plan design changes, and new clinical programs as assigned.
- Provide clinical guidance and respond to medication-related questions from internal departments and other stakeholders.
- Support the development, implementation, and maintenance of pharmacy policies, procedures, and clinical review guidelines.
- Identify opportunities for quality improvement, operational efficiency, and enhanced pharmacy practice.
- Contribute to drug utilization review (DUR) initiatives for Medicaid and Medicare populations.
- Participate in the coordination of Medicare Medication Therapy Management (MTM) programs, as applicable.
- Collaborate with case management teams and participate in clinical rounds or case presentations when needed.
- Maintain accurate documentation of clinical reviews and decisions in accordance with established procedures and regulatory requirements.
- Adapt to changing business priorities, clinical guidelines, and operational requirements while maintaining productivity and quality standards.
- Perform additional duties as assigned.
Required Qualifications
Education
- Bachelor's degree in Pharmacy or Doctor of Pharmacy (Pharm.D.) from an accredited institution.
Licensure
- Current, unrestricted pharmacist license in a U.S. state.
- Ability to obtain or maintain the state licensure required to support assigned business needs.
Preferred state licenses: North Carolina, Arizona, Kansas, Texas, Indiana, Georgia, New Jersey, California, and Florida.
Candidates with multiple active state pharmacist licenses may be preferred based on operational needs.
Experience
- At least 1 year of experience in retail, hospital, managed care, or Pharmacy Benefit Management (PBM) pharmacy.
- Prior experience reviewing medication prior authorizations within a managed care organization or PBM environment.
- Experience evaluating clinical documentation and applying established medical necessity criteria.
- Working knowledge of pharmacotherapy, medication safety, drug utilization, and clinical coverage policies.
Preferred Qualifications
- Experience reviewing prior authorization requests for medical benefit drugs, particularly buy-and-bill medications.
- Familiarity with Medicare, Medicaid, Exchange, and Commercial health plan requirements.
- Experience with clinical review workflows, medication coverage determinations, and utilization management processes.
- Proficiency with Microsoft Outlook, Teams, SharePoint, and Excel.
- Strong understanding of clinical guidelines, pharmacy policies, and evidence-based medication management.
Required Skills and Competencies
- Clinical decision-making: Ability to make decisive, accurate, and evidence-based clinical determinations using established criteria.
- Flexibility and adaptability: Ability to adjust to evolving clinical guidelines, business priorities, and operational requirements.
- Learning agility: Ability to quickly learn new systems, processes, policies, and medication review requirements.
- Attention to detail: Ability to assess clinical documentation thoroughly and maintain accurate case records.
- Time management: Ability to manage a high volume of cases while meeting daily productivity and quality targets.
- Communication: Strong written and verbal communication skills for documenting clinical decisions and collaborating with internal stakeholders.
- Problem-solving: Ability to analyze complex medication requests and identify appropriate next steps.
- Accountability and integrity: Commitment to transparent decision-making, professional ethics, and consistent adherence to clinical policies.
Key Responsibilities and Daily Workflow
The selected candidate will work within a pharmacy team responsible for reviewing prior authorization requests for medical benefit drugs across multiple lines of business.
Typical activities include:
- Reviewing provider-submitted medication requests and supporting clinical documentation.
- Applying established criteria to determine whether requested medications meet coverage and medical necessity requirements.
- Completing and documenting clinical determinations accurately and efficiently.
- Managing a high-volume caseload while maintaining required quality and turnaround times.
- Collaborating with colleagues and internal departments to resolve clinical questions and support consistent decision-making.
Performance Expectations
The successful candidate will be expected to meet the following performance standards:
- Production goal: 90% RFS production attainment, measured daily and monthly.
- Daily productivity: Approximately 47 completed cases per day.
- Quality goal: 99.9% quality performance.
- Turnaround time: Process cases within applicable operational and regulatory requirements.
Candidates should be comfortable balancing productivity, clinical accuracy, and quality standards in a fast-paced utilization management environment.
Work Environment and Schedule
- Fully remote position.
- Standard eight-hour work shift, typically 9:00 a.m. to 5:30 p.m. in the employee's local time zone.
- Requires reliable internet access and the ability to work effectively in a remote environment.
- Regular use of clinical review systems and Microsoft Office collaboration tools.
- Collaboration with pharmacy team members and internal stakeholders across multiple lines of business.
Interview and Selection Process
- Interview format: Microsoft Teams.
- Candidate review timeline: Approximately 2 4 days after shortlisting.
- Assessment: No additional vendor-administered testing specified.
Candidates will be evaluated on their pharmacist licensure, clinical knowledge, prior authorization review experience, decision-making ability, adaptability, and ability to meet productivity and quality expectations
Job Tags
Hourly pay, Permanent employment, Contract work, Temporary work, Work at office, Local area, Remote work, Shift work