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The OccuNet Company is an innovative company striving to reduce the cost of healthcare. We are a passionate group of people that care about affordable access to healthcare without sacrificing experience. We strive to make healthcare more intelligent, streamlined, and cost-effective. We offer industry-leading capabilities on negotiations-driven levers to contain rising healthcare costs while taking an experience-centric approach improving the health and well-being of those we serve. We pride ourselves on our tight knit culture based on the ‘outward mindset’ philosophy, emphasizing empathy, mutual respect, and seeing each other as “whole people.” We have an ambitious vision and are growing quickly. We are seeking team members who are excited about our growth, seeking to thrive in a fast-paced environment, and enthusiastic about developing their skills and career alongside us.
Job Description
Job Title: Prior Authorization Pharmacist
Department: Clinical (Operations)
Reports To: Sr Vice President of Clinical
Position Summary
The Prior Authorization Pharmacist is responsible for the clinical review and evaluation of pharmacy prior authorization requests to ensure appropriate medication use in accordance with member benefits, evidence-based clinical criteria, and client-specific coverage policies. This position supports high-quality, cost-effective pharmaceutical care by making timely coverage determinations, identifying clinically appropriate therapeutic alternatives, coordinating appeals, and collaborating with prescribers, members, and internal stakeholders.
The Prior Authorization Pharmacist also provides clinical leadership to the pharmacy operations team by supporting utilization management initiatives, developing and maintaining clinical criteria, identifying cost-saving opportunities, and driving continuous quality improvement across clinical programs.
Essential Duties and Responsibilities
Clinical Review and Utilization Management
Review and evaluate prior authorization requests in accordance with member benefit plans, clinical guidelines, client policies, and regulatory requirements.
Complete prior authorization reviews within established turnaround time requirements while maintaining high standards of clinical quality and accuracy.
Apply evidence-based clinical criteria to determine medical necessity and appropriateness of requested drug therapies.
Identify opportunities for therapeutic optimization and cost-effective medication management while maintaining clinical efficacy and patient safety.
Collaborate with prescribing providers to recommend clinically appropriate, cost-effective formulary alternatives when applicable.
Provide clinical recommendations that promote appropriate medication utilization and adherence to formulary management strategies.
Appeals and Clinical Consultation
Coordinate the clinical review of appeals related to pharmacy benefit determinations.
Communicate coverage decisions and clinical rationale to providers, members, pharmacy staff, and other stakeholders.
Receive and initiate telephone calls with providers and members to obtain additional clinical information or provide clinical consultation regarding pharmacy benefit decisions.
Serve as a clinical resource for member advocates, account executives, and other internal departments by providing guidance on pharmacy benefit policies, coverage criteria, and medication-related questions.
Clinical Program Development
Assist in the development, implementation, and maintenance of prior authorization criteria, clinical guidelines, and utilization management programs using principles of evidence-based medicine.
Support formulary management initiatives, including step therapy, quantity management, and other clinical programs designed to improve quality and control pharmacy costs.
Evaluate emerging clinical literature and therapeutic guidelines to support ongoing updates to coverage criteria.
Customer Service
Respond to inquiries from members, providers, pharmacy staff, clients, and internal departments regarding pharmacy benefits, authorization status, formulary requirements, and coverage determinations.
Communicate professionally and effectively with all stakeholders.
Data Analysis and Reporting
Analyze pharmacy utilization data to identify prescribing trends, utilization patterns, and opportunities for cost savings and quality improvement.
Generate, review, and interpret prior authorization reports.
Present findings and recommendations to clinical leadership and other stakeholders as appropriate.
Monitor key performance indicators and identify opportunities to improve clinical and operational performance.
Leadership and Quality Improvement
Continuously evaluate and improve prior authorization workflows and drug utilization management processes to enhance efficiency, quality, and member experience.
Provide clinical leadership and mentorship to clinical associates.
Motivate and support clinical staff to achieve or exceed established productivity, quality, and service standards.
Assist with onboarding, education, and ongoing training of clinical staff regarding new clinical programs, policies, procedures, and regulatory requirements.
Participate in quality assurance activities, audits, accreditation initiatives, and process improvement projects.
Compliance
Ensure all clinical activities are conducted in accordance with HIPAA, client requirements, accreditation standards (including NCQA & URAC where applicable), and federal and state regulations.
Maintain complete, accurate, and timely documentation within pharmacy management systems.
Perform additional duties and special projects as assigned.
Qualifications Education Bachelor of Science in Pharmacy (BSPharm) or Doctor of Pharmacy (Pharm.D.) degree from an accredited college of pharmacy.
Licensure Active, current, and unrestricted Pharmacist license.
Licensure in additional states may be required based on business needs.
Experience Required Minimum of one (1) year of direct prior authorization or utilization management experience.
Experience applying evidence-based clinical guidelines in pharmacy practice.
Experience reviewing pharmacy prior authorizations and appeals.
Experience with formulary management, drug utilization review (DUR), and medication therapy management.
Experience supporting NCQA, URAC, or other accreditation standards.
Knowledge, Skills, and Abilities
Strong clinical knowledge of pharmacotherapy and evidence-based medicine.
Knowledge of pharmacy benefit management operations and utilization management principles.
Working knowledge of the Medi-Span drug database, including GPI drug classification.
Excellent clinical judgment and critical thinking skills.
Proficiency with Microsoft Excel, Microsoft Word, and pharmacy management systems.
Excellent written and verbal communication skills.
Strong interpersonal and customer service skills with the ability to effectively communicate with providers, clients, members, and internal stakeholders.
Strong organizational skills and the ability to prioritize multiple competing responsibilities while meeting established deadlines.
Ability to work independently and collaboratively within a multidisciplinary team.
Core Competencies
Clinical Excellence
Evidence-Based Decision Making
Customer Focus
Leadership and Team Development
Collaboration
Critical Thinking
Quality Improvement
Data Analysis
Communication
Work Environment
This position is primarily performed in an office or remote office environment and requires prolonged periods of sitting while working on a computer. Responsibilities include frequent telephone communication and interaction with providers, members, pharmacy staff, clients, and internal stakeholders.
Work Schedule
Full-time
Monday through Friday
Standard business hours with flexibility to meet operational needs.
Compliance
The Prior Authorization Pharmacist is responsible for performing all duties in accordance with company policies and procedures, client contracts, accreditation standards (including NCQA and URAC, where applicable), HIPAA privacy and security requirements, and all applicable federal and state laws.
Culture and Opportunities
We pride ourselves on our outward mindset – supporting each other and putting the team and the clients we serve first
High-growth environment with clear opportunities for career growth