Clinical Review Pharmacist – 6-month, Full-time Contract

Job Description:

• Review and make timely, evidence-based decisions on prior authorizations and appeals using clinical guidelines and benefit criteria
• Ensure compliance with federal, state, and internal regulations across applicable lines of business
• Accurately document clinical decisions and maintain thorough records in accordance with regulatory and accreditation (URAC/NCQA) utilization review standards
• Provide support to members, prescribers, and pharmacies by responding to clinical inquiries
• Stay current with clinical prescribing guidelines, internal policies, and regulatory changes
• Follow internal procedures, job aids, and HIPAA guidelines to protect patient privacy and data security
• Identify and report potential fraud, waste, and abuse (FWA)
• Support training and development of new and existing team members
• Assist leadership with special projects, process improvements, and operational initiatives

Requirements:

• Doctor of Pharmacy (PharmD.) or Bachelor of Science in Pharmacy (B.S. Pharm) from an ACPE-accredited school of pharmacy
• Active, unrestricted, pharmacist license in state of residence
• Minimum of 2 years of pharmacy practice experience
• Strong communication, writing, and organizational skills
• Ability to manage multiple priorities in a high-volume, metric-driven environment
• General understanding of drug information, clinical guidelines, formulary design, and utilization management strategies
• Flexible and adaptable to changes
• Availability to work after hours, weekends, and holidays on a rotating or fixed schedule
• Preferred: One year of prior authorization or utilization management experience
• Preferred: One year experience in managed care or pharmacy benefit management (PBM)
• Preferred: Direct experience conducting prior authorization reviews, clinical appeals, formulary exceptions, step therapy evaluations, and quantity limit reviews
• Preferred: Experience in Google Workspace (Gmail, Docs, Sheets, and Drive)

Benefits:

• Time off programs
• Medical insurance
• Dental insurance
• Vision insurance
• Mental health support
• Paid parental leave
• Life insurance
• Disability insurance
• 401(k)
• Potential eligibility for bonuses, commissions, or equity