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Clinical Pharmacy Review Specialist
Presbyterian Healthcare Services. Work under the direct supervision of a Clinical Pharmacist within the Pharmacy Services Department .
Posted 11/6/2026full-timeSanta Fe • New Mexico • United StatesMid-LevelSenior💰 $20 - $34 per hourWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in pharmacy benefits management, including prior authorization processes and clinical data analysis. Proficient in communicating benefit coverage and interpreting pharmacy and medical benefits while adhering to regulations and policies.
Highest-signal resume keywords
Certified Pharmacy Technician-PTCBPharmacy Benefits ManagementPrior Authorization EvaluationDrug Information SkillsMedicare Part D Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Case ReviewPharmacy Laws and RegulationsDosage CalculationsPrescription Documentation RequirementsPharmaceutical Products KnowledgeMedical TerminologyHIPAA RegulationsMedication Therapy ManagementClaims ProcessingCritical Thinking
Soft Skills
Effective Oral CommunicationEffective Written CommunicationSense of UrgencyAttention to DetailCustomer Service
Tools & Technologies
Claims Processing System
Certifications & Qualifications
Certified Pharmacy Technician-PTCB
Industry Keywords
Managed Care Pharmacy PrinciplesHealth InsurancePrescription BenefitsRetail PharmacyMedicaid Programs
About the role
Key responsibilities & impact- Work under the direct supervision of a Clinical Pharmacist within the Pharmacy Services Department
- Provide clinical support for clinical case review submissions
- Prepare and research clinical data for coverage determinations, prior authorizations, direct member reimbursement, point of sale determinations, and appeals and grievances
- Perform first-level review and evaluation of prior authorization requests for appropriateness, policy deviations, contraindications, coverage criteria, and protocols
- Review documentation and request additional information from prescribing physicians to establish medical necessity
- Forward cases to clinical pharmacists for second-level review
- Apply critical thinking and use reference documents, clinical criteria, policies, procedures, and desktop procedures
- Enter and interpret prior authorization documentation in the appropriate claims processing system
- Communicate benefit coverage, formulary and non-formulary criteria, and related policies to members, providers, pharmacists, and pharmacy staff
- Respond to member pharmacy coverage inquiries by phone or online
- Analyze rejected pharmacy claims and identify resolutions for successful claims submission and processing
- Evaluate or interpret information related to drug administration and treatments
- Assist the Clinical Pharmacist with member medication regimen review and Medication Therapy Management
- Know and interpret pharmacy and medical benefits
- Perform other duties as assigned
Requirements
What you’ll need- GED or High School diploma is required
- Certified Pharmacy Technician-PTCB is required
- Experience with pharmacy benefits management, health insurance and or prescription benefits is preferred
- Retail Pharmacy experience preferred
- Managed care customer service experience preferred
- Drug Information skills
- Experience with Medicare Part D insurance and Medicaid programs
- Knowledge of drug nomenclature, basic pharmacology, dosage calculations, units of measure, prescription filling techniques, prescription documentation requirements, pharmacy laws and regulations, basic managed care pharmacy principles and insurance coverage issues
- Knowledge of pharmaceutical products, including oral, injectable, infusion products and chemotherapy drugs
- Knowledge of medical terminology and HIPAA regulations
- Effective oral and written communication skills
- Ability to meet established deadlines timely, accurately and with a sense of urgency
Benefits
Comp & perks- Medical insurance
- Dental insurance
- Vision insurance
- Short-term disability insurance
- Long-term disability insurance
- Group term life insurance
- Optional voluntary benefits
- Employee Wellness rewards program
- Gift cards for participating in wellness activities