Prior Authorization Pharmacist - 250954

The Prior Authorization Pharmacist is responsible for performing clinical reviews of medication authorization requests to ensure coverage decisions align with established clinical guidelines, regulatory requirements, and pharmacy benefit policies. This position supports appropriate medication utilization by applying evidence-based criteria while balancing quality of care, patient safety, and operational efficiency.Working in a collaborative PBM environment, the pharmacist serves as a clinical resource for internal teams, providers, and pharmacy partners by delivering timely, accurate, and well-documented coverage determinations.Primary ResponsibilitiesEvaluate prior authorization requests for both formulary and non-formulary medications using evidence-based clinical guidelines, FDA labeling, plan criteria, and utilization management protocols.Render clinical determinations, including approvals, denials, or alternative recommendations, within established service-level expectations.Maintain thorough documentation of clinical reviews, supporting rationale, provider communications, and final decisions within designated systems.Communicate authorization outcomes clearly and professionally to prescribers, pharmacies, and internal business partners.Recommend clinically appropriate therapeutic alternatives, formulary options, or step therapy substitutions when applicable.Partner with Clinical Services and Operations teams to promote consistency, quality, and accuracy in authorization decisions.Provide clinical support for escalated medication reviews, benefit interpretation, and coverage policy questions.Ensure all reviews are completed in accordance with state and federal regulations, accreditation requirements, and internal compliance standards.Contribute to the evaluation and maintenance of clinical guidelines, utilization management programs, and pharmacy policies.Support formulary initiatives, client-specific clinical programs, reporting, and operational projects as needed.Assist with onboarding and education of pharmacists and support staff regarding clinical criteria, drug therapies, and authorization processes.Participate in quality assurance activities, audits, workflow optimization, and continuous process improvement efforts.Perform additional responsibilities as assigned to support departmental and organizational objectives.Minimum QualificationsDoctor of Pharmacy (PharmD) or Bachelor of Science in Pharmacy from an accredited program.Active, unrestricted pharmacist license in the United States.Prior experience in prior authorization, utilization management, managed care, pharmacy benefit management (PBM), or payer pharmacy operations.Comprehensive knowledge of pharmacotherapy, formulary management, specialty medications, and evidence-based treatment guidelines.Strong clinical reasoning, analytical thinking, and documentation abilities.Experience utilizing prior authorization platforms, pharmacy benefit systems, and electronic documentation tools.Excellent verbal and written communication skills with the ability to collaborate effectively across multidisciplinary teams.Demonstrated ability to manage competing priorities while maintaining accuracy in a deadline-driven environment.Commitment to confidentiality, professionalism, and regulatory compliance.Preferred QualificationsExperience reviewing specialty medications, biologics, or other complex therapeutic categories.Previous employment within a PBM, health plan, or managed care organization.Familiarity with formulary development, utilization management strategy, or clinical policy creation.Knowledge of pharmacy claims processing systems, prior authorization automation platforms, or pharmacy informatics tools.Experience supporting quality improvement initiatives or developing clinical workflow enhancements.Core CompetenciesClinical evaluation and evidence-based decision makingPrior authorization and utilization management expertisePharmacy benefit interpretationRegulatory and accreditation complianceClear clinical documentationCross-functional collaborationAttention to detail and quality assuranceTime management and organizational skills