Prior Authorization Clinical Pharmacist

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is required by law.

About the role

As a Prior Authorization Clinical Pharmacist, you will evaluate and manage the selection and utilization of pharmaceuticals to ensure safe, effective, and cost-efficient medication use. This role supports key clinical pharmacy programs, including Drug Utilization Review (DUR), Drug Information Services (DIS), and formulary management.

Responsibilities

• Research and synthesize detailed clinical data related to pharmaceuticals.
• Prepare and present therapeutic class reviews and drug monograph information to the Pharmacy and Therapeutics Committee.
• Review and approve or deny coverage for pharmaceuticals (as permitted by state/federal law or state/federal program contracts) based on medical necessity criteria, coordinating with internal stakeholders or health plan medical directors as needed.
• Serve as a clinical resource to other pharmacists on areas such as prospective, inpatient, and retrospective DURs, providing dosage conversion and clinical support for therapeutic interventions.
• Prepare information for network physicians.
• Provide clinical guidance for therapeutic interventions, dosage conversions, and evidence-based medication use.
• Develop and communicate drug information and recommendations to network physicians and clinical teams.

Requirements

• BA/BS in Pharmacy.
• Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of work experience; or any combination of education and experience, which would provide an equivalent background.
• Active unrestricted state license to practice pharmacy as a Registered Pharmacist (RPh).
• For associates working within Puerto Rico who are member or patient-facing either in a clinical setting or in the Best Transportation unit, a current PR health certificate and a current PR Law 300 certificate are required.
• Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or appeals consideration.

Preferred Qualifications

• Active North Carolina Pharmacist (RPh) license.
• Prior Authorization experience supporting NC Medicaid, Commercial, and Specialty Medicaid pharmacy programs.
• Knowledge of Medicaid and Commercial pharmacy benefit management processes.

Skills

• Strong oral, written, and interpersonal communication skills.
• Problem-solving and facilitation skills.
• Analytical skills.

Benefits

• Merit increases, paid holidays, and Paid Time Off.
• Incentive bonus programs (unless covered by a collective bargaining agreement).
• Medical, dental, vision, short and long-term disability benefits.
• 401(k) with company match and stock purchase plan.
• Life insurance, wellness programs, and financial education resources.

Schedule

Elevance Health operates in a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week, and potentially several times per week, unless specified as primarily virtual by the hiring manager.