Prior Authorizations Pharmacist (Full-Time)

Clinical Review and Utilization Management:

• Review and evaluate prior authorization requests in accordance with member benefit plans and clinical guidelines.
• Apply evidence-based criteria to determine medical necessity and recommend therapeutic alternatives.
• Ensure timely and accurate coverage determinations while maintaining high clinical quality.

Appeals and Clinical Consultation:

• Coordinate clinical review of appeals and communicate coverage decisions to providers and members.
• Serve as a clinical resource for internal departments and stakeholders.
• Initiate and receive calls to obtain additional clinical information or provide consultation.

Clinical Program Development and Quality Improvement:

• Assist in developing prior authorization criteria and utilization management programs.
• Evaluate emerging clinical literature to update coverage criteria.
• Participate in quality assurance, audits, and process improvement initiatives.