Prior Authorization Clinical Pharmacist
Core
Evaluates and manages pharmaceutical selection and utilization to ensure safe, effective, and cost-efficient medication use; reviews coverage based on medical necessity criteria.
Role type
Senior IC clinical pharmacist (prior authorization & drug utilization review)
Builds
Drug Utilization Review (DUR) programs, Drug Information Services (DIS), and formulary management
Domain
Health insurance / Pharmacy Benefit Management (PBM)
Deliverable
production ML models | product features | dashboards & analysis | client delivery
Required skills
Clinical data research and synthesis, therapeutic class review preparation, drug monograph development, medical necessity criteria evaluation, stakeholder coordination, clinical guidance for therapeutic interventions, dosage conversion, evidence-based medication use, drug information communication
Preferred skills
PharmD degree, PBM experience, Prior Authorization experience, Specialty Medication experience
Technologies
None explicitly stated
Responsibilities
Researches and synthesizes detailed clinical data related to pharmaceuticals; Prepares and presents therapeutic class reviews and drug monographs to the Pharmacy and Therapeutics Committee; Reviews and approves or denies coverage for pharmaceuticals based on medical necessity criteria; Serves as a clinical resource for prospective, inpatient, and retrospective DURs; Provides clinical guidance for therapeutic interventions and dosage conversions; Develops and communicates drug information and recommendations to network physicians and clinical teams
Seniority
Mid-level, hands-on IC