Clinical Pharmacy Reviewer (Pharmacist) - Remote

Dane Street, LLC; United States; Remote; USD 110,000 - 140,000; Full time

Benefits offered by this job

Remote culture

Professional growth

Comprehensive benefits

Great Place to Work Certified

Job summary

Dane Street seeks a Clinical Pharmacy Reviewer (Pharmacist) to evaluate complex prior authorization requests, appeals, and coverage determinations in order to ensure clinical appropriateness and evidence-based practice.

The role requires interpreting drug criteria, formulary guidelines, step therapy, and quantity limits for specialty and non-specialty medications, with emphasis on Drug Utilization Review and medical necessity.

Qualifications

• Minimum 3 years PA/Appeals review in PBM environment.
• Doctor of Pharmacy degree and active pharmacist license in the U.S.

Responsibilities

• Evaluate complex prior authorization requests and appeals for clinical appropriateness.
• Interpret formulary guidelines, step therapy, and quantity limits for medications.
• Perform Drug Utilization Review to uphold medical necessity and regulatory standards.

Skills

Prior Authorization review

Appeals review

DUR knowledge

Formulary management

Medicare Part D knowledge

Regulatory compliance

Education

PharmD degree

Job description

The Clinical Pharmacy Reviewer (Pharmacist) evaluates complex prior authorization requests, appeals, and medication coverage determinations to ensure clinical appropriateness and compliance with evidence-based guidelines. Acting as a subject matter expert in pharmacy benefit management, this role interprets complex drug criteria, formulary guidelines, step therapy, and quantity limits for specialty and non-specialty medications. Through rigorous Drug Utilization Review (DUR) and objective decision-making, the Clinical Pharmacy Reviewer upholds medical necessity standards, directly impacting Dane Street's commitment to high-quality healthcare delivery and regulatory excellence.

At Dane Street, we believe exceptional employee experiences create exceptional client experiences. Our culture is built on collaboration, continuous improvement, accountability, and care.

We care for our customers, we care for our employees, and we care for one another. Every team member plays an important role in creating an environment where people feel respected, supported, empowered to grow, and inspired to do meaningful work.

Requirements

EDUCATION/CREDENTIALS:

• Doctor of Pharmacy (PharmD) degree from an accredited university.
• Active, unencumbered pharmacist license in any U.S. State.

Must Haves:

• Minimum of 3 years of Prior Authorization and/or Appeals review experience within a PBM environment.

Preferred Qualifications:

• 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

Why Join Dane Street?

• 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

WORK FROM HOME TECHNICAL REQUIREMENTS:

Supply and support their own internet services.

Maintaining an uninterrupted internet connection is a requirement of all work-from-home positions.

Equal Opportunity Statement:

At Dane Street, caring for people is at the heart of what we do. We are committed to creating an inclusive workplace where every employee feels respected, valued, and empowered to contribute. We provide equal employment opportunities to all applicants and employees and make employment decisions based on qualifications, merit, business needs, and without regard to race, color, religion, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law.