Insurance Pharmacy Claims Analyst | Remote

Type: Hourly contract
Compensation: $75 per hour
Location: Remote
Commitment: 10-40 hrs/week

Responsibilities

• Process and manage prior authorisation requests for speciality medications, biologics, and high-cost pharmaceuticals.
• Review clinical documentation and pharmacy benefit criteria to determine medical necessity for drug authorisations.
• Evaluate AI-generated pharmacy prior authorisation recommendations for accuracy and compliance.
• Coordinate with prescribers, speciality pharmacies, and payers to obtain medication authorisations.
• Manage appeals for denied pharmacy authorisations, including peer-to-peer requests and exception processes.
• Track authorisation status, approval rates, and denial trends to identify process improvement opportunities.
• Ensure compliance with payer-specific pharmacy benefit requirements and CMS Part D guidelines.
• Annotate AI outputs and provide structured feedback to support AI training datasets.

Requirements

• Have strong relevant experience in pharmacy prior authorisation, speciality medication access, or pharmacy benefit management.
• Deep knowledge of speciality drug formularies, step therapy protocols, and payer PA criteria.
• Experience with speciality pharmacy platforms and pharmacy benefit management systems.
• Familiarity with Medicare Part D coverage determination and exception processes.
• Exceptional written and verbal English communication skills.
• High attention to detail with the ability to evaluate clinical documentation and AI-generated outputs.