Clinical Pharmacist
Core
Reviews prior authorization requests for non-formulary medications to ensure clinical appropriateness and cost-effectiveness for health plan members.
Role type
Utilization management clinical pharmacist
Builds
Prior authorization decisions and formulary management for health plans
Domain
Health insurance / Utilization management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical judgment, medical policy criteria application, drug reference research, data compilation, provider communication, formulary management
Preferred skills
Managed care experience, utilization management, prior authorization, health plan pharmacy operations
Technologies
Discoverer, IT Department reporting tools
Responsibilities
Review prior authorization requests and pharmacy technician recommendations, verify member eligibility and prescription benefits, evaluate prescription claim history and lab values, apply medical policy criteria to determine approval, communicate with physicians regarding plan benefits and formulary alternatives, compile data for reporting on drug utilization and audit claims, support National P&T Committee
Seniority
Entry-level to Mid-level, hands-on IC
