Prior Authorization Pharmacist

Medix; Maryland; Remote; USD 90,000 - 130,000; Full time

Job summary

Medix is seeking a remote clinical Pharmacist to evaluate prior authorization requests for formulary and non-formulary medications. You will apply evidence-based guidelines and regulatory standards to render timely clinical determinations and partner with providers, pharmacies, and health plan teams.

In this role, you will review medical records, document the clinical rationale, and communicate determinations clearly.

Qualifications

• Active, unrestricted Pharmacist license in your state of residence.
• Hands-on experience conducting clinical reviews and rendering PA decisions.
• Background in utilization management, managed care, PBM, or health plan pharmacy operations.
• Experience with PBM systems, PA platforms, and remote documentation software.
• Excellent verbal and written communication with providers and plan staff.

Responsibilities

• Clinical Review & Determination: Evaluate PA requests for formulary and non-formulary meds; render timely approval, denial, or modification decisions based on guidelines and standards.
• Documentation & Communication: Maintain precise records of clinical rationale and case details; clearly communicate determinations and coverage policies to prescribers and pharmacies.
• Operational & Team Support: Serve as a clinical resource for escalated inquiries; advise on benefit interpretation, step-therapy substitutions, formulary exceptions, and workflow troubleshooting.

Skills

Pharmacist license

Clinical PA reviews

PBM experience

Communication

Remote collaboration

Education

PharmD (Doctor of Pharmacy)

Tools

PBM systems

PA platforms

EHR software

Job description

Position Overview

In this remote clinical role, you will evaluate prior authorization requests for formulary and non-formulary medications. You will leverage evidence-based guidelines and regulatory standards to render timely clinical determinations while serving as a trusted partner to healthcare providers, pharmacies, and health plan teams.

Shift:

• Monday - Friday (8am - 5pm PST)

Required Qualifications

• Licensure: Active, unrestricted Pharmacist (PharmD or RPh) license in your state of residence.
• Direct Experience: Must have hands-on experience as a Licensed Pharmacist conducting clinical reviews and rendering decisions on prior authorizations (PAs).
• Domain Knowledge: Proven background working within utilization management, managed care, PBM, or health plan pharmacy operations.
• Technical Proficiency: Demonstrated experience working within pharmacy benefit management (PBM) systems, prior authorization platforms, and electronic health/documentation software in a remote setup.
• Communication: Outstanding verbal and written communication skills for engaging with providers, health plan representatives, and clinical peers telephonically and digitally.

Key Responsibilities

• Clinical Review & Determination: Evaluate prior authorization requests for formulary and non-formulary medications; render timely approval, denial, or modification decisions based on evidence-based guidelines, clinical criteria, and regulatory standards.
• Documentation & Communication: Maintain precise records of clinical rationale and case details in internal systems while clearly communicating determinations, coverage policies, and alternative therapeutic options to prescribers and pharmacies.
• Operational & Team Support: Serve as a subject-matter clinical resource for escalated inquiries, offering guidance on benefit interpretation, step-therapy substitutions, formulary exceptions, and workflow troubleshooting.

We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients