AI-Driven PA Specialist (Pharmacy Access)

Mercor; New York (NY); Remote; USD 90,000 - 130,000; Full time

Job summary

Mercor is partnering with a leading AI research lab to optimize access to high-cost therapies through expert medication prior authorisation specialists. You will help shape AI-driven PBM workflows, reviewing clinical documentation, coordinating with prescribers and payers, and ensuring compliance across Medicare Part D and commercial plans.

We seek a candidate with 5+ years of PA experience; CPHT or CPAP credentials are a plus.

Qualifications

• 5+ years of experience in pharmacy prior authorisation, speciality medication access, or PBM.
• Deep knowledge of speciality drug formularies, step therapy protocols, and payer PA criteria across commercial and government payers.
• Experience with speciality pharmacy platforms and PBM systems.
• Familiarity with Medicare Part D coverage determination and exception processes.
• Exceptional written and verbal English communication skills.
• High attention to detail with the ability to evaluate clinical documentation and AI-generated outputs.

Responsibilities

• Process and manage prior authorisation requests for speciality medications across commercial, Medicare Part D, and Medicaid payers.
• Review clinical documentation and pharmacy benefit criteria to determine medical necessity for speciality drug authorisations.
• Evaluate AI-generated pharmacy prior authorisation recommendations for accuracy, completeness, and payer compliance.
• Coordinate with prescribers, speciality pharmacies, and payers to obtain timely medication authorisations.
• Manage appeals for denied pharmacy authorisations, including peer-to-peer requests and exception processes.
• Navigate payer formulary, step therapy requirements, and speciality drug coverage policies.
• Track authorisation status, approval rates, and denial trends to identify process improvement opportunities.
• Ensure compliance with payer-specific pharmacy benefit requirements and CMS Part D guidelines.
• Annotate AI outputs and provide structured feedback to support AI training datasets.

Skills

Attention to detail

PBM knowledge

Prior authorization

Education

CPHT or CPAP credential

Tools

PBM systems

Job description

Mercor is partnering with a leading AI research lab to optimize access to high-cost therapies through expert medication prior authorisation specialists. You will help shape AI-driven PBM workflows, reviewing clinical documentation, coordinating with prescribers and payers, and ensuring compliance across Medicare Part D and commercial plans.

We seek a candidate with 5+ years of PA experience; CPHT or CPAP credentials are a plus.