Prior Authorization Pharmacist

About the role

The Prior Authorization Pharmacist conducts clinical reviews of medication authorization requests to ensure decisions align with clinical guidelines, regulatory requirements, and pharmacy benefit policies. Working within a collaborative PBM environment, the pharmacist provides timely, accurate coverage determinations for internal teams, providers, and pharmacy partners.

Key responsibilities

• Evaluate prior authorization requests for formulary and non‑formulary medications using evidence‑based guidelines, FDA labeling, plan criteria, and utilization management protocols.
• Render clinical determinations—approvals, denials, or alternative recommendations—within established service‑level expectations.
• Document clinical reviews, rationale, provider communications, and final decisions in designated systems.
• Communicate outcomes clearly to prescribers, pharmacies, and internal business partners.
• Recommend therapeutic alternatives, formulary options, or step‑therapy substitutions when appropriate.
• Partner with Clinical Services and Operations to ensure consistency, quality, and accuracy of decisions.
• Support escalated medication reviews, benefit interpretation, and coverage policy questions.
• Contribute to the maintenance of clinical guidelines, utilization management programs, and pharmacy policies.
• Assist with onboarding and education of pharmacists and support staff.
• Participate in quality assurance, audits, workflow optimization, and continuous improvement activities.

Required profile

• Doctor 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, 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.

Required skills

• Prior authorization platforms
• Pharmacy benefit systems
• Electronic documentation systems