Senior Clinical Review Operations Pharmacist
Core
Senior clinical subject matter expert driving operational efficiency, quality assurance, and process improvements within a Prior Authorization team for a Health-Tech PBM.
Role type
Senior IC clinical operations pharmacist
Builds
Scalable clinical review workflows and operational tools for member prior authorization
Domain
US Healthcare / Pharmacy Benefit Management (PBM)
Required skills
Prior authorization review, clinical operations, process optimization, clinical mentorship, complex case escalation, P&T committee collaboration, KPI/SLA management, drug product/dose calculations, claim adjudication rules
Preferred skills
Technology-driven efficiency, cross-functional collaboration, adaptability to evolving guidelines
Technologies
Mac, MS Office, G-Suite
Responsibilities
Identify operational gaps and champion technology-driven solutions; Serve as clinical peer lead providing guidance and coaching; Act as senior contact for complex clinical cases and appeals; Partner with internal teams on eligibility and claims adjudication; Collaborate with P&T Committee to develop clinical criteria; Meet or exceed individual KPIs and TAT SLAs; Drive adoption of new technology and protocols
Seniority
Senior, hands-on IC