Job Description

Title: Clinical Pharmacist I
Location: 100% Remote
Duration: 6-Month Contract (Potential Extension)
Schedule: Monday Friday, 10:00 AM 6:30 PM EST
Overtime: Occasional OT may be required

Pay Range: XXXXXXXXXXX - XXXXXXXXXXX Per hr. on w2.

Position Overview

Seeking a Clinical Pharmacist to support pharmacy benefit management operations through clinical review of medication prior authorization requests and coverage determinations across Medicaid, Medicare, and Marketplace health plans.

This role requires strong clinical decision-making skills, knowledge of pharmacy benefit management principles, and the ability to efficiently review high volumes of prior authorization requests while maintaining quality and compliance standards.

The Clinical Pharmacist will collaborate with internal departments, case management teams, and pharmacy operations to ensure appropriate medication utilization, formulary compliance, and optimal member outcomes.

Ideal Candidate

The ideal candidate is a licensed Pharmacist with strong managed care, mail-order, or clinical review experience who can efficiently review high volumes of medication authorization requests while maintaining accuracy, compliance, and quality standards. Candidates with prior authorization, Medicare, Medicaid, MTM, and formulary management experience will be highly preferred.

Key Responsibilities

Clinical Review & Prior Authorization

• Review and evaluate medication prior authorization requests and coverage determinations.
• Assess clinical appropriateness based on evidence-based guidelines, formulary requirements, and regulatory standards.
• Analyze medication requests for safety, efficacy, medical necessity, and cost-effectiveness.
• Make clinical recommendations regarding approval, denial, or modification of medication requests.
• Review approximately 140 160 prior authorization requests and coverage determinations daily.

Formulary Management

• Assist in developing and maintaining standard and custom formularies.
• Recommend formulary enhancements and plan design improvements.
• Support implementation of clinical pharmacy programs and utilization management initiatives.

Clinical Program Support

• Develop and maintain clinical criteria for medication coverage decisions.
• Participate in Drug Utilization Review (DUR) initiatives for Medicaid and Medicare populations.
• Assist in Medication Therapy Management (MTM) program activities.
• Support pharmacy quality improvement and performance enhancement initiatives.

Cross-Functional Collaboration

• Provide clinical guidance to internal business partners and operational teams.
• Support case management teams through clinical consultation and member case reviews.
• Participate in interdisciplinary discussions and clinical rounds when needed.
• Respond to clinical inquiries regarding medication utilization and coverage policies.

Compliance & Quality

• Maintain compliance with CMS, Medicare, Medicaid, NCQA, and state regulatory requirements.
• Ensure adherence to pharmacy department policies and procedures.
• Support development and maintenance of pharmacy operational standards.
• Identify opportunities for process improvement and quality enhancement.

Required Qualifications

Education

• Bachelor of Science in Pharmacy (BSPharm) or Doctor of Pharmacy (PharmD)

Licensure

• Active and unrestricted Pharmacist license in any U.S. state

Experience

• 1 3 years of pharmacy experience in:
  • Managed Care Pharmacy
  • Retail Pharmacy
  • Mail Order Pharmacy
  • Hospital Pharmacy
  • Pharmacy Residency Program

Preferred Qualifications

• Prior Authorization Review experience
• Coverage Determination experience
• Medicare Part D knowledge
• Medicaid Pharmacy experience
• MTM (Medication Therapy Management) experience
• Drug Utilization Review (DUR) experience
• PBM (Pharmacy Benefit Management) experience
• Remote pharmacist experience
• High-volume clinical review experience

Top Skills

• Clinical Decision Making
• Prior Authorization Review
• Coverage Determinations
• Formulary Management
• Managed Care Pharmacy
• Medication Therapy Management (MTM)
• Drug Utilization Review (DUR)
• Pharmacy Benefit Management (PBM)
• Adaptability
• Ability to Learn New Systems Quickly
• Strong Analytical Skills
• Time Management
• Regulatory Compliance
• Written & Verbal Communication

Job Tags

Similar Jobs