Licensed Clinical Pharmacy Reviewer

Job Summary

Evaluating complex prior authorization requests and medication coverage determinations, the remote Licensed Clinical Pharmacy Reviewer will ensure clinical appropriateness and compliance with evidence-based guidelines while acting as a subject matter expert in pharmacy benefit management.

Key responsibilities

• Review and assess prior authorization requests and appeals for clinical appropriateness
• Interpret complex drug criteria, formulary guidelines, and medication coverage policies
• Conduct Drug Utilization Reviews (DUR) to uphold medical necessity standards

Required qualifications

• Doctor of Pharmacy (PharmD) degree from an accredited university
• Active, unencumbered pharmacist license in any U.S. State
• Minimum of 3 years of experience in Prior Authorization and/or Appeals review within a PBM environment
• Knowledge of Medicare Part D and Medicaid pharmacy benefits
• In-depth understanding of Drug Utilization Review (DUR) processes