Prior Authorization Pharmacist

Insight Global; United States; Remote; USD 120,000 - 150,000; Full time

Job summary

Insight Global is seeking a Pharmacist, Prior Authorization & Appeals, to review PA requests and determine coverage based on clinical guidelines and plan benefits. You will work closely with physicians, pharmacy staff, and internal teams to ensure compliant, cost-effective therapies while meeting productivity and quality targets.

Remote-capable, with minimal supervision, you must have a current state license and Bachelors or Doctor of Pharmacy degree; 6+ months of healthcare customer service

Qualifications

• Pharmacist licensed in the state of work.
• 6+ months of healthcare customer service.
• Technology savvy and able to work remotely with minimal supervision.
• Comfortable in a production-based, high-volume environment.

Responsibilities

• Review and evaluate prior authorization and appeals requests to determine coverage based on clinical guidelines, pharmacy policies, and health plan benefits.
• Collaborate with physicians, healthcare providers, pharmacy technicians, and internal teams to gather and assess clinical information and make evidence-based coverage determinations.
• Recommend formulary-compliant and cost-effective treatment alternatives while ensuring compliance with federal and state regulations.
• Document decisions per internal protocols, auditing standards, and confidentiality policies; manage case workload with daily priorities and productivity targets.

Skills

Customer service

Technology savvy

Remote work capability

Team collaboration

Education

Bachelor's or Doctor of Pharmacy

Active State Pharmacist License

Job description

Bachelors or Doctor of Pharmacy; Active State Pharmacist License

-Current Licensed Pharmacist within the state of work

-6+ months of customer service/customer relations with healthcare professionals

-Technology savvy

-Comfortable with production-based environment

-Ability to perform responsibilities and duties remotely with little to no supervision

-Comfortable in a fast-paced, high-volume workload

-Ability to be adaptable, team-oriented culture requiring flexibility and adaptability to changing business needs.

Job Description:

The Pharmacist, Prior Authorization (PA) & Appeals, is responsible for reviewing and evaluating prior authorization and appeals requests to determine coverage based on clinical guidelines, pharmacy policies, and health plan benefits. In this fast-paced, high-volume environment, the pharmacist works closely with physicians, healthcare providers, pharmacy technicians, and internal teams to gather and assess clinical information, make evidence-based coverage determinations, recommend formulary-compliant and cost-effective treatment alternatives, and ensure compliance with federal and state regulations. The role requires strong clinical judgment, attention to detail, effective communication skills, and the ability to manage competing priorities while meeting productivity and quality standards. Additionally, the pharmacist supports quality assurance initiatives, resolves provider and pharmacy inquiries, participates in process improvement efforts, and contributes to a collaborative, customer-focused team environment. Maintain full compliance with state and federal pharmacy laws, Medicare Part D, Medicaid, and commercial benefit regulations. Accurately document case decisions in accordance with internal protocols, auditing standards, and confidentiality policies. Effectively manage case volume by organizing workload, setting daily priorities, and meeting productivity and quality benchmarks. Adapt to fluctuating demands while maintaining accuracy and professionalism under pressure.