Clinical Pharmacist

About the role

The Clinical Pharmacist processes review prior authorization requests for non‑formulary medications for clinical appropriateness, ensuring members receive the most effective and cost‑effective pharmacological therapies. The role requires authorization to work in the U.S. without employment‑based visa sponsorship (sponsorship not available for H‑1B, L‑1, O‑1, H‑1B1, F‑1, J‑1, OPT, or CPT). Experience in managed care, utilization management, prior authorization, or health plan pharmacy operations is preferred, and the position includes participation in periodic weekend and holiday coverage rotations to support business needs.

Responsibilities

• Review completed prior authorization requests from providers and/or pharmacy technician recommendations (denials, formulary alternatives, comments, attachments) for clinical appropriateness.
• Verify member’s ID number and date of birth.
• Verify member’s eligibility in the appropriate health plan eligibility system.
• Record carrier and group number when applicable.
• Check for prior prior authorization decisions.
• Verify coverage in the member’s prescription benefit when necessary.
• Verify coverage in the member’s health plan benefit when necessary.
• Evaluate prescription claim history.
• Review chart notes and/or lab values.
• Identify provider specialty when appropriate.
• Apply Medical Policy Criteria to prior authorization requests.
• Evaluate whether the request meets criteria for approval.
• Review requests using professional clinical judgment on a case‑by‑case basis.
• Develop and draft criteria for non‑formulary medications not addressed by P&T Committee guidelines.
• Research and contribute drug references and clinical information to facilitate prior authorization review (via fax/phone to physicians or memos to pharmacy technicians).
• Communicate with physicians regarding prior authorization: plan benefits, exclusions, quantity limits, age restrictions, formulary alternatives.
• Retrieve and collect data through reporting resources (e.g., Discoverer, IT Department).
• Compile data for reporting: drug utilization of non‑formulary drugs, overturned IPS recommended denials, audit pharmacy claims >$200.
• Suggest addition or deletion of drugs to/from the formulary.
• Update quantity/day or age‑limit parameters.
• Support National P&T Committee activities.
• Perform other tasks that arise in the course of the above duties.

Requirements

• Bachelor’s or Doctorate of Pharmacy degree.
• One year of prior experience.
• Current, valid, unrestricted Pharmacist license in the state of employment, credentialed by the health plan; may require additional state licensure based on business needs.

Qualifications

• Experience in managed care, utilization management, prior authorization, or health plan pharmacy operations is preferred.

Skills

• Professional clinical judgment applied on a case‑by‑case basis.
• Ability to develop and draft criteria for non‑formulary medications.
• Skill in researching and contributing drug references and clinical information.
• Effective communication with physicians regarding plan benefits, exclusions, quantity limits, age restrictions, and formulary alternatives.
• Proficiency in retrieving and reporting data using tools such as Discoverer or IT Department resources.
• Ability to audit pharmacy claims (>$200), analyze drug utilization, and recommend formulary changes.
• Capability to verify member eligibility, coverage, prior authorization history, and prescription claim details.
• Aptitude for reviewing chart notes, lab values, and identifying provider specialties.
• Experience applying Medical Policy Criteria to prior authorization requests