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Job Summary
The Pharmacist will serve as a licensed healthcare professional within the Prior Authorization Department and will be responsible for making determinations on prior authorization requests for coverage of pharmaceutical products. Determinations include medical necessity and benefit decisions made in accordance with established pharmacy guidelines, prior authorization criteria, applicable industry regulations, and clinical judgment. The role involves working independently on reviews and decision-making while collaborating with pharmacists, supervisors, and team members to meet established quality standards and customer performance requirements. This position may include a rotating weekend schedule based on business needs.

Key Responsibilities
• Review and make determinations on prior authorization requests for pharmaceutical product coverage.
• Make medical necessity and benefit decisions in accordance with established pharmacy guidelines and prior authorization criteria.
• Apply applicable industry regulations and clinical judgment when reviewing coverage requests.
• Independently manage assigned reviews and make appropriate coverage determinations with support from senior pharmacists and supervisors as needed.
• Collaborate with team members to meet or exceed established quality standards and customer performance requirements.
• Provide clinical support to the Customer Care Center.
• Engage healthcare providers in discussions to support prior authorization determinations.
• Support Fraud and Abuse program oversight activities.
• Stay current with relevant industry trends and regulatory changes.
• Maintain knowledge of operational directives and customer reference materials.
• Participate in a rotating weekend schedule if required based on business needs.

Required Qualifications
• Bachelor’s degree.
• Current Pharmacist license.
• Proficient PC skills within a Windows-based environment.
• Ability to independently review information and make appropriate clinical and coverage determinations.
• Ability to work effectively within a collaborative team environment.

Preferred Qualifications
• PharmD degree preferred.
• Prior Authorization or Coverage Determination experience preferred.

Certifications
• Current Pharmacist license is required.