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Clinical Pharmacy Reviewer, Pharmacist
Dane Street. Evaluate complex prior authorization requests, appeals, and medication coverage determinations .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Expertise in evaluating prior authorization requests and appeals, with a strong focus on clinical appropriateness and compliance with evidence-based guidelines. Proficient in Drug Utilization Review (DUR) and knowledgeable in pharmacy benefit management, Medicare Part D, and Medicaid pharmacy benefits.
Highest-signal resume keywords
Doctor Of Pharmacy (PharmD)Active Pharmacist LicensePrior Authorization Review ExperienceDrug Utilization Review (DUR)Pharmacy Benefit Management
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Prior Authorization EvaluationMedication Coverage DeterminationClinical Guideline InterpretationFormulary ManagementStep Therapy KnowledgeQuantity Limit ProgramsSpecialty Medications KnowledgeEvidence-Based Guidelines ComplianceMedical Necessity StandardsRegulatory Excellence
Industry Keywords
Medicare Part DMedicaid Pharmacy BenefitsCommercial Insurance Pharmacy BenefitsPharmacy Benefit Management (PBM)Drug Criteria Interpretation
About the role
Key responsibilities & impact- Evaluate complex prior authorization requests, appeals, and medication coverage determinations
- Ensure clinical appropriateness and compliance with evidence-based guidelines
- Act as a subject matter expert in pharmacy benefit management
- Interpret complex drug criteria, formulary guidelines, step therapy, and quantity limits for specialty and non-specialty medications
- Conduct rigorous Drug Utilization Review (DUR)
- Make objective decisions supporting medical necessity standards
- Contribute to high-quality healthcare delivery and regulatory excellence
Requirements
What you’ll need- Doctor of Pharmacy (PharmD) degree from an accredited university
- Active, unencumbered pharmacist license in any U.S. State
- Minimum of 3 years of Prior Authorization and/or Appeals review experience within a PBM environment
- Experience with Medicare Part D and Medicaid pharmacy benefits
- Knowledge of commercial insurance pharmacy benefits and formulary management strategies
- Knowledge of step therapy requirements, quantity limit programs, and specialty medications
- In-depth knowledge of Drug Utilization Review (DUR)
- Demonstrated ability to interpret and apply complex clinical guidelines
Benefits
Comp & perks- Collaborative remote culture
- Professional growth opportunities
- Meaningful work supporting the healthcare industry
- Comprehensive benefits
- Great Place to Work Certified since 2021
- Commitment to employee development
- Employer-provided? No: candidates must supply and support their own internet services
- Uninterrupted internet connection for work-from-home employment